Prophylactic antibiotic use in stroke patients

Hospital acquired infections (HAIs) are a devastating complication that can increase morbidity and mortality, particularly post-stroke due to the disruption in the blood-brain barrier. 1-17  The prevalence of HAI post-stroke ranges, with the majority of reports indicating the prevalence of HAI in stroke patients is between 20-40%.18-21  This prevalence is higher for stroke patients than in the general hospitalized population (3.5-15%), indicating a particularly at risk population. 22  To date, the results from randomized clinical trials assessing prophylactic antibiotic use in stroke patients have been mixed, with the most recent trials suggesting prophylactic antibiotic use does not promote better functional outcome post-stroke and only moderately decreases the proportion of HAI.23-30

The current study by Westendorp et al., assessed whether prophylactic antibiotic use in stroke patients would be more cost effective than standard of care.  This study was a secondary analysis of an open label trial investigating cost, an outcome that was not pre-specified in the design of the trial.30  The authors assessed the cost-effectiveness on change in mRS and quality adjusted life years. While this is an interesting outcome to assess, the small gain in cost effectiveness for antibiotic use vs. standard of care does not push the risk/benefit ratio in favor of preventative antibiotic usage.  Furthermore, the cost-effectiveness calculations did not take into consideration the high cost of dealing with overgrowth infection, such as C difficile, or antibiotic resistance, a looming public health issue that is becoming more problematic each day.  In addition to this very important limitation, the bootstrapping analysis yielded different results than the standard cost-effectiveness assessment.  In the simulation studies, those who were treated with prophylactic antibiotics, the per-unit reduction in mRS resulted in less costs.  While this was an interesting simulation finding, the fact remains that prophylactic antibiotic use in this study did not result in a decrease in mRS, nor a decrease in costs.  Furthermore, this paper brings up an interesting question- When should patient care be driven by cost and when should it be driven by outcomes?  Prophylactic antibiotic use did not change outcomes, and the risks associated with prophylactic antibiotics are high, therefore, does cost reduction justify the use?  I would argue that it does not.  As devastating as post-stroke HAIs are, antibiotic resistance and infectious overgrowth are both more costly, and can have considerable ramifications on patient outcomes.  Regardless, HAI post-stroke remains a major clinical concern, and efforts to identify the highest at risk groups for potential targeted prophylactic antibiotic intervention would be a better argument than cost.  The trials that showed the greatest benefit from prophylactic antibiotics in stroke were those that focused on severe strokes. These components need to be investigated more thoroughly before arguing for instituting prophylactic antibiotic use in stroke patients.

 

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Amelia Boehme, PhD

Amelia Boehme, PhD

Columbia University, Mailman School of Public Health, Assistant Professor Epidemiology (In Neurology and in the Sergievsky Cinter)

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