Craig J Smith1, Amit K Kishore2, Andy Vail2, Angel Chamorro2, Javier Garau2, Stephen J Hopkins2, Mario Di Napoli2, Lalit Kalra2, Peter Langhorne2, Joan Montaner2, Christine Roffe2, Anthony G Rudd2, Pippa J Tyrrell2, Diederik van de Beek2, Mark Woodhead2, Andreas Meisel2. 1. From the Stroke and Vascular Research Centre (C.J.S., A.K.K., S.J.H., P.J.T.) and Centre for Biostatistics (A.V.), University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, United Kingdom; Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de Terrassa, Barcelona, Spain (J.G.); Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy (M.D.N.); Clinical Neurosciences, King's College Hospital NHS Foundation Trust, London, United Kingdom (L.K.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom (P.L.); Laboratorio de Investigación Neurovascular, Unidad Neurovascular, Servicio de Neurología Hospital Vall d' Hebron, Barcelona, Spain (J.M.); IBIS Stroke Programme, Hospital Virgen del Rocio, Sevilla, Spain (J.M.); Keele University Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Stoke-on-Trent, United Kingdom (C.R.); Department of Health and Social Care, Kings College, London, United Kingdom (A.G.R.); Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands (D.v.d.B.); Faculty of Medical and Human Sciences, University of Manchester (M.W.) and Department of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (M.W.); and NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, Germany (A.M.). Craig.Smith-2@manchester.ac.uk. 2. From the Stroke and Vascular Research Centre (C.J.S., A.K.K., S.J.H., P.J.T.) and Centre for Biostatistics (A.V.), University of Manchester, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, Salford, United Kingdom; Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain (A.C.); Department of Medicine, Hospital Universitari Mutua de Terrassa, Barcelona, Spain (J.G.); Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy (M.D.N.); Clinical Neurosciences, King's College Hospital NHS Foundation Trust, London, United Kingdom (L.K.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, United Kingdom (P.L.); Laboratorio de Investigación Neurovascular, Unidad Neurovascular, Servicio de Neurología Hospital Vall d' Hebron, Barcelona, Spain (J.M.); IBIS Stroke Programme, Hospital Virgen del Rocio, Sevilla, Spain (J.M.); Keele University Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Stoke-on-Trent, United Kingdom (C.R.); Department of Health and Social Care, Kings College, London, United Kingdom (A.G.R.); Department of Neurology, Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands (D.v.d.B.); Faculty of Medical and Human Sciences, University of Manchester (M.W.) and Department of Respiratory Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (M.W.); and NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, Germany (A.M.).
Abstract
BACKGROUND AND PURPOSE: Lower respiratory tract infections frequently complicate stroke and adversely affect outcome. There is currently no agreed terminology or gold-standard diagnostic criteria for the spectrum of lower respiratory tract infections complicating stroke, which has implications for clinical practice and research. The aim of this consensus was to propose standardized terminology and operational diagnostic criteria for lower respiratory tract infections complicating acute stroke. METHODS: Systematic literature searches of multiple electronic databases were undertaken. An evidence review and 2 rounds of consensus consultation were completed before a final consensus meeting in September 2014, held in Manchester, United Kingdom. Consensus was defined a priori as ≥75% agreement between the consensus group members. RESULTS: Consensus was reached for the following: (1) stroke-associated pneumonia (SAP) is the recommended terminology for the spectrum of lower respiratory tract infections within the first 7 days after stroke onset; (2) modified Centers for Disease Control and Prevention (CDC) criteria are proposed for SAP as follows-probable SAP: CDC criteria met, but typical chest x-ray changes absent even after repeat or serial chest x-ray; definite SAP: CDC criteria met, including typical chest x-ray changes; (3) there is limited evidence for a diagnostic role of white blood cell count or C-reactive protein in SAP; and (4) there is insufficient evidence for the use of other biomarkers (eg, procalcitonin). CONCLUSIONS: Consensus operational criteria for the terminology and diagnosis of SAP are proposed based on the CDC criteria. These require prospective evaluation in patients with stroke to determine their reliability, validity, impact on clinician behaviors (including antibiotic prescribing), and clinical outcomes.
BACKGROUND AND PURPOSE: Lower respiratory tract infections frequently complicate stroke and adversely affect outcome. There is currently no agreed terminology or gold-standard diagnostic criteria for the spectrum of lower respiratory tract infections complicating stroke, which has implications for clinical practice and research. The aim of this consensus was to propose standardized terminology and operational diagnostic criteria for lower respiratory tract infections complicating acute stroke. METHODS: Systematic literature searches of multiple electronic databases were undertaken. An evidence review and 2 rounds of consensus consultation were completed before a final consensus meeting in September 2014, held in Manchester, United Kingdom. Consensus was defined a priori as ≥75% agreement between the consensus group members. RESULTS: Consensus was reached for the following: (1) stroke-associated pneumonia (SAP) is the recommended terminology for the spectrum of lower respiratory tract infections within the first 7 days after stroke onset; (2) modified Centers for Disease Control and Prevention (CDC) criteria are proposed for SAP as follows-probable SAP: CDC criteria met, but typical chest x-ray changes absent even after repeat or serial chest x-ray; definite SAP: CDC criteria met, including typical chest x-ray changes; (3) there is limited evidence for a diagnostic role of white blood cell count or C-reactive protein in SAP; and (4) there is insufficient evidence for the use of other biomarkers (eg, procalcitonin). CONCLUSIONS: Consensus operational criteria for the terminology and diagnosis of SAP are proposed based on the CDC criteria. These require prospective evaluation in patients with stroke to determine their reliability, validity, impact on clinician behaviors (including antibiotic prescribing), and clinical outcomes.
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