Personal Antibiotic Use Density: A New and Effective Evaluation Index of Antibiotics Use in Intracerebral Hemorrhage Patients with Stroke-Associated Infection

Abstract

Background: Intracerebral hemorrhage is associated with higher incidence of stroke-associated infection than other types of stroke as well as more common antibiotic use. The potential relationship between the use of antibiotics and prognosis of intracerebral hemorrhage patients with SAI is unclear. We aimed to examine the association between the personal antibiotic use density (PAUD) and prognosis of intracerebral hemorrhage patients with SAI. Methods: We continuously collected data on 162 intracerebral hemorrhage patients with SAI who came to our hospital from January 2014 to September 2016, and we retrospectively analyzed their general clinical data and antibiotic use. Patients were divided into a survival group (n = 111) and death group (n = 51) according to in-hospital prognosis, and the two groups were compared in terms of clinical data and PAUD. In-hospital mortality was compared among three groups defined by PAUD tertiles: low PAUD (<0.38, n = 53), intermediate PAUD (0.38-0.75, n = 55) and high PAUD (≥0.75, n = 54). Multivariate regression was used to identify independent risk factors for prognosis. PAUD tertiles were used for survival analysis. Spearman correlation was used to explore correlations between PAUD and clinical factors. Findings: In-hospital mortality was significantly higher in intracerebral hemorrhage patients with SAI [31.5% (51/162)] than in the total population of intracerebral hemorrhage patients treated during the study period [15.6% (89/570), P < 0.001]. Bleeding volume, rate of combined intraventricular hemorrhage, National Institutes of Health Stroke Scale (NIHSS) score, Intracerebral Hemorrhage Scale score, and PAUD were significantly higher among patients who died than among those who survived, while the Glasgow Coma Scale score and length of stay were significantly lower (P < 0.05). PAUD was an independent risk factor for in-hospital mortality even after adjusting for relevant factors (OR 2.396, 95%CI 1.412-4.067, P = 0.001). In-hospital mortality was significantly lower in the low (OR 0.451, 95%CI 0.222-0.913, P = 0.027) and intermediate PAUD (OR 0.211, 95%CI 0.090-0.493, P < 0.001) groups than in the high PAUD group. Overall cumulative in-hospital survival was significantly higher for low and intermediate PAUD groups than for the high PAUD group (log rank test, P < 0.001). PAUD correlated positively with NIHSS score (r = 0.224, P < 0.001) and in-hospital mortality (r = 0.268, P = 0.001). Interpretation: The study shows that incidence of SAI among patients with intracerebral hemorrhage is relatively high, and pulmonary infections are the predominant cause. SAI in intracerebral hemorrhage patients is associated with higher in-hospital mortality, and PAUD is closely related to in-hospital prognosis of intracerebral hemorrhage patients with SAI. Higher PAUD is not associated with better prognosis and may, in fact, increase risk of death. Funding Statement: The work was supported by grants from the Seed Fund (Natural Science Class) of Shanghai University of Medicine & Health Sciences (HMSF-17-21-026), Foundation of the Public Health Bureau of Jiading (2017-KY-06, 2017-KY-09) and New Key Subjects of Jiading District (2017-ZD-03). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: The study protocol was approved by the Ethics Review Board of Jiading District Central Hospital (2017-ZD-03). Written informed consent was waived by the Ethics Review Board due to the retrospective nature of the study. Patient data were anonymized.