Abstract
IntroductionInfection after stroke is associated with unfavorable outcome. Randomized controlled studies did not show benefit of preventive antibiotics in stroke but lacked power for subgroup analyses. Aim of this study is to assess whether preventive antibiotic therapy after stroke improves functional outcome for specific patient groups in an individual patient data meta-analysis.Patients and methodsWe searched MEDLINE (1946–7 May 2021), Embase (1947–7 May 2021), CENTRAL (17th September 2021), trial registries, cross-checked references and contacted researchers for randomized controlled trials of preventive antibiotic therapy versus placebo or standard care in ischemic or hemorrhagic stroke patients. Meta-analysis was performed by a one-step and two-step approach. Primary outcome was functional outcome adjusted for age and stroke severity. Secondary outcomes were infections and mortality.Results4197 patients from nine trials were included. Preventive antibiotic therapy was not associated with a shift in functional outcome (mRS) at 3 months (OR1.13, 95%CI 0.98–1.31) or unfavorable functional outcome (mRS 3–6) (OR0.85, 95%CI 0.60–1.19). Preventive antibiotics did not improve functional outcome in pre-defined subgroups (age, stroke severity, timing and type of antibiotic therapy, pneumonia prediction scores, dysphagia, type of stroke, and type of trial). Preventive antibiotics reduced infections (276/2066 (13.4%) in the preventive antibiotic group vs. 417/2059 (20.3%) in the control group, OR 0.60, 95% CI 0.51–0.71, p < 0.001), but not pneumonia (191/2066 (9.2%) in the preventive antibiotic group vs. 205/2061 (9.9%) in the control group (OR 0.92 (0.75–1.14), p = 0.450).Discussion and conclusionPreventive antibiotic therapy did not benefit any subgroup of patients with acute stroke and currently cannot be recommended.
Highlights
Infection after stroke is associated with unfavorable outcome
18 publications were identified of which five were excluded (2 were not a randomized study, in 1 the randomization procedure was unclear, 1 study only included patients with indwelling catheters and in 1 study treatment with preventive antibiotic therapy was guided by procalcitonin levels; Supplementary table 2)
Investigators of 13 trials were approached and 10 authors shared their data (2 studies were eligible for inclusion but we received no response from authors,[6,15 1] study was eligible but an author responded that the database was no longer available[16]; Supplementary table 3a)
Summary
Infection after stroke is associated with unfavorable outcome. Randomized controlled studies did not show benefit of preventive antibiotics in stroke but lacked power for subgroup analyses. Aim of this study is to assess whether preventive antibiotic therapy after stroke improves functional outcome for specific patient groups in an individual patient data meta-analysis. Stroke is an important cause of death, accounting for 11.8% of deaths worldwide, and is the third most common cause of disability.[1] Infections occur frequently after stroke and have been associated with unfavorable disease outcome.[2] Several randomized clinical trials have investigated antibiotics to prevent infections after stroke.[3,4,5,6,7,8] In a Cochrane systematic review, preventive antibiotic therapy compared to placebo or standard care did not reduce mortality or unfavorable outcome after stroke.[9] Preventive antibiotics do reduce the number of infections after stroke and it could well be that some patients still benefit but not others, and how to select patients who could benefit is unclear.
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
