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ORIGINAL RESEARCH

Scoring Of Post Stroke Pneumonia In Uttaradit

Hospital
This article was published in the following Dove Press journal:
Journal of Multidisciplinary Healthcare

Nichakarn Leangpanich 1 Background: Stroke is a disease which occurs when the blood supply to the brain is
Yanin Chuphanitsakun 1 interrupted, depriving brain tissue of oxygen, resulting in cell death. The symptoms of stroke
Kanyaros Pakaranodom 1 include: numbness, paraplegia, dysarthria, ataxia, etc. The most common complication is
Kunlachat Kerdjarern 1 infection. The highest death rates among hospitalized stroke patients are from pneumonia.
Objective: To develop a score for predicting post-stroke pneumonia infection and identify
Watcharapol Poonual 2
risk factors for patients with post-stroke pneumonia.
1
Medical Education Center, Faculty of Study design: Retrospective case-control.
Medicine, Naresuan University, Uttaradit
Hospital, Uttaradit 53000, Thailand; Setting: Uttaradit hospital (the tertiary hospital), Thailand.
2
Medical Education Research Center, Method: A retrospective data study was conducted at Uttaradit hospital, Thailand from
Uttaradit Hospital, Uttaradit 53000,
January 2014 to October 2018 in which all of the subjects were diagnosed with either
Thailand
stroke with pneumonia or without pneumonia by a physician. The selected 324 stroke
patients were divided into two groups: 108 patients were stroke with pneumonia and
Video abstract 216 patients were stroke without pneumonia. This study involved data collection and
analysis of study characteristics to develop a predictive score for post-stroke
pneumonia.
Results: This study identified risk factors and developed a score for predicting post-stroke
pneumonia infection by using significant covariates (duration of admission; 1–10 days=0
points, 11–20 days=1 point, more than 20 days=2.5 points, Cardiovascular disease=1.5
points, Nasogastric tube=2 points, Urinary tract infection=1 point). This score was inter-
preted to three groups; low risk (<2 points), moderate risk (2.5–4 points), and high risk (>4
points). Sensitivity was 80.56% and specificity was 93.52%.
Conclusion: A simple prediction tool was developed that uses only four clinical variables to
predict risk of post-stroke pneumonia with high sensitivity and specificity.
Point your SmartPhone at the code above. If you have a Keywords: pneumonia, stroke, risk factor, risk score
QR code reader the video abstract will appear. Or use:
https://youtu.be/ovkeS7xE7gI

Background
Stroke occurs when a blood vessel is either blocked by a clot or ruptured,
causing damage to the brain tissue.1 That causes a variety of symptoms such as
weakness or numbness of the face, arm, or leg, difficulty speaking or under-
standing speech, difficulty walking, and difficulty seeing with one or both
eyes.2 Some stroke patients develop complications while hospitalized, which
Correspondence: Watcharapol Poonual
Medical Education Center Uttaradit are mostly brain edema, pneumonia, urinary tract infection, seizures, clinical
Hospital, Jadsadabordin Road, Tambon depression, bedsores, limb contractures, shoulder pain, and deep venous
Ta – it Amphur Muang, Uttaradit 53000,
Thailand thrombosis (DVT).3
Tel +6655 832601-3
According to the literature review, the most common complications of stroke are
Fax +66 55 411543
Email poonual@gmail.com post-stroke infection (30%). Rate of pneumonia and urinary tract infection after

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Leangpanich et al Dovepress

stroke were 10%.4 Pneumonia has a mortality rate of 35% A retrospective case-control study accumulated with a
of all post-stroke death.5,6 Symptoms of pneumonia may related literature review proved that atrial fibrillation12 is
include fever, cough, and dyspnea.7 Meanwhile fever is one of the predisposing risk factors among pneumonia
usually hidden by using aspirin in a stroke patient,8 also statistically. So we used two independent proportions of
cough is barely found in stroke patients as well.9 Dyspnea the presence and absence of pneumonia in stroke patients
may be a result of underlying disease such as heart failure by using power 90%, alpha=0.05, p1=0.249, p2=0.513,
or COPD.10 The initially normal chest x-rays are more and the index to reference proportion is 1:2 which
likely in pneumonia.11 sampled 324 patients to 10 index cases, and 216 refer-
Therefore, we developed a score for predicting post- ence cases.
stroke pneumonia infection with proper surveillance and
management. Variable Data
Independent variable: age group, sex, length of stay,
Objectives lesion, NIHSS SCORE, underlying disease, medical treat-
● To develop a score for predicting post-stroke pneu- ment such as Endotracheal intubation, Nasogastric tube,
monia infection; Percutaneous gastrostomy, and Urinary catheter, other
● To identify risk factors of patients with post-stroke complications, eg, epileptic seizure, Sepsis, Urinary tract
pneumonia while admitted to Uttaradit hospital. infection, Heart failure, and arrhythmia.
Dependent variable: pneumonia in stroke patients.

Methods Descriptive Statistics

Study design: Retrospective case controlled. Categorical data: count data and percentage were analyzed
Population: stroke patients admitted at Uttaradit hospi- using the chi-squared test and Fisher’s exact test.
tal between January 2014 and August 2018. Numerical data: Median, Interquartile Range was ana-
Target population: 108 Stroke patients with pneumo- lyzed using student t-test or Wilcoxon rank-sum test.
nia. (Pneumonia was recorded by the treating physician
based on clinical symptoms of lung infection in combi- Analytic Statistics
nation with clinical signs such as rales on chest auscul- A univariable logistic regression model was used to ana-
tation and chest X ray findings suggestive for lyze each explanatory variable, interpreted as odds ratio,
pneumonia supported by laboratory tests such as com- 95% CI, and p-value.
plete blood count.) A multivariable logistic regression model was used to
Control Population: 216 stroke patients without analyze all explanatory variables interpreted as odds ratio,
pneumonia. 95% CI, and p-value.
Exclusion Criteria: Community-acquired pneumonia
patients. Results
The study was designed as a case-control analysis of General Characteristics
data from an academic affiliated community hospital that General characteristics analysis from 324 stroke patients
retrospectively collects data from stroke patients admitted of whom 108 had pneumonia and 206 didn’t have pneu-
at Uttaradit hospital between January 2014 and August monia were not different between the groups in sex, age
2018. The study was divided into two stroke patient group, lesion of right hemisphere, both hemisphere, brain
groups: with or without pneumonia (108 and 216, respec- stem or cerebellum, and ventricle or sinus, Diabetes, atrial
tively). The exclusion criteria was Community-acquired fibrillation, cardiovascular disease, Hyperlipidemia, and
pneumonia. COPD.
The stroke without pneumonia group had more lesions
Statistical Methods of the left hemisphere than the pneumonia group
From 6,088 stroke patients who were hospitalized in statistically.
Uttaradit hospital between 2014–2018, stroke with pneu- The length of stay, lesion at Basal ganglion or thala-
monia was diagnosed in 409, and 5,679 were stroke mus, and Hypertension were significantly higher in those
patients without pneumonia. stroke patients who had pneumonia (Table 1).

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Table 1 General Characteristics Of Stroke Patients With Pneumonia Versus Without Pneumonia
General Characteristics Stroke Patients With Pneumonia Stroke Patients Without Pneumonia p-value

n % n %

Age group
Less than 40 years 3 2.8 10 4.6 0.637
40–80 years 87 80.6 176 81.5
More than 80 years 18 16.6 30 13.9
Mean (SD) 67.2 (13.1) 65.3 (14.3)

Sex
Female 52 48.2 89 41.2 0.235
Male 56 51.8 127 58.8

Length of stay, median (interquartile range) 24 (27) 3 (4) <0.001

Lesion
Left hemisphere 28 26.0 80 37.0 0.046
Right hemisphere 26 24.0 61 28.2 0.425
Both hemisphere 5 4.6 14 6.5 0.504
Brainstem or Cerebellum 8 7.4 27 12.5 0.164
Basal ganglion and thalamus 39 36.1 33 15.3 <0.001
Ventricle and sinus 2 1.9 1 0.5 0.259

Hypertension
No 26 24.0 0 37.0 0.019
Yes 82 76.0 136 63.0

Diabetes mellitus
No 89 82.4 177 81.9 0.918
Yes 19 17.6 39 18.1

Atrial fibrillation
No 96 88.9 196 90.4 0.598
Yes 12 11.1 20 9.3

Cardiovascular disease
No 102 94.4 212 98.1 0.069
Yes 6 5.6 4 1.9

Hyperlipidemia
No 71 65.7 118 54.6 0.056
Yes 37 34.3 98 45.4

COPD
No 106 98.2 216 100 0.110
Yes 2 1.8 0 0

Medical Treatment Odds Ratio Of Pneumonia In Stroke

In sites with pneumonia, endotracheal intubation, Patients
Nasogastric tube, and Urinary catheter were significantly The 40–80 years age groups of stroke patients had a
higher than those sites without pneumonia (Table 2).
1.6-fold increaded odds of developing pneumonia.
Other Complications Likewise, a stay of 11–20 days and more than 20 days
Those stroke patients who developed pneumonia had sig- increased the odds 11.5- and 141.8-fold, respectively. The
nificantly higher rates of epileptic seizure, Sepsis, Urinary complications of cardiovascular disease and urinary tract
tract infection, and Heart failure (Table 3). infection increased the odds 3.1- and 18.2-fold,

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Table 2 Medical Treatment Of Stroke Patients With Pneumonia Versus Without Pneumonia
Medical Treatment Stroke Patients With Pneumonia Stroke Patients Without Pneumonia p-value

n % n %

Endotracheal intubation
No 18 16.7 170 78.7 <0.001
Yes 90 83.3 46 21.3

Nasogastric tube
No 8 7.4 171 79.2 <0.001
Yes 100 92.6 45 20.8

Urinary catheter
No 12 11.1 176 81.5 <0.001
Yes 96 88.9 40 18.5

Table 3 Other Complications Of Stroke Patients With Pneumonia Versus Without Pneumonia
Other Complications Stroke Patients With Pneumonia Stroke Patients Without Pneumonia p-value

n % n %

Seizure
No 89 82.4 209 96.8 <0.001
Yes 19 18.6 7 3.2

Sepsis
No 82 75.9 212 98.2 <0.001
Yes 26 24.1 4 1.8

Urinary tract infection

No 86 79.6 213 98.6 <0.001
Yes 22 20.4 3 1.4

Heart failure
No 100 92.6 213 98.6 0.008
Yes 8 7.4 3 1.4

Arrhythmia
No 99 91.7 207 95.8 0.130
Yes 9 8.3 9 4.2

respectively. Meanwhile, stroke patients had a nasogastric The score was divided into three groups, those with
tube had an increased risk of developing pneumonia of lower than 2 points were defined as a lower risk group,
47.5-fold (Table 4). while the medium risk group was counted for 2.5–4 points,
and more than 4 points for the high risk group (Table 5)
Score For Predicting Post-Stroke with 80.56% sensitivity and 93.52% specificity. There was
a positive predictive value of 86.14 and a negative pre-
Pneumonia Infection
dictive value of 90.58.
After analysis by multivariable logistic regression, there
were four variables to make a score for predicting post-
stroke pneumonia infection, which is Length of stay that Discussion
divided into three intervals (1–10 days=0, 11–20 days=1, Risk factors of post-stroke pneumonia patients were iden-
and more than 20 days=2.5), 1.5 points for cardiovascular tified and predicting score was developed with high sensi-
disease, 2 points for nasogastric tube, and 1.5 points for tivity and specificity by using four variables that are easy
urinary tract infection. and convenient for screening and setting priority to proper

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Table 4 Odd Ratio Of Developing Pneumonia In Stroke Patients

OR Univariate Analysis Multivariate Analysis

95% CI p-value 95% CI p-value

Age group
<40 years 1.00
40–80 years 1.6 0.410–9.536 0.453 1.355–251.994 0.029
>80 years 2 0.430–12.664 0.332 0.821–244.213 0.068

Sex
Female 0.8 0.462–1.234 0.235 0.361–2.518 0.922
Male 1.00

Length of stay
0–10 days 1.00
11–20 days 11.5 4.930–26.637 <0.001 1.670–17.074 0.005
>20 days 141.8 45.027–567.248 <0.001 13.723–504.628 <0.001

Lesion
Left hemisphere 0.2 0.003–3.548 0.117 0.536–253.647 0.118
Right hemisphere 0.2 0.004–4.343 0.176 0.410–205.328 0.162
Both hemispheres 0.2 0.003–4.514 0.163 0.034–22.203 0.935
Brainstem or Cerebellum 0.1 0.002–3.392 0.098 0.247–151.984 0.269
Basal ganglion and thalamus 0.6 0.010–11.907 0.670 0.771–428.300 0.072
Ventricle and sinus 1.00

Hypertension
No 1.00
Yes 1.9 1.074–3.259 0.019 0.241–2.007 0.503

Diabetes mellitus
No 1.00
Yes 1.0 0.498–1.836 0.918 0.353–4.398 0.733

Atrial fibrillation
No 1.00
Yes 1.2 0.523–2.758 0.598 0.075–1.843 0.225

Cardiovascular disease
No 1.00
Yes 3.1 0.719–15.302 0.069 1.342–157.205 0.028

Hyperlipidemia
No 1.00
Yes 0.6 0.376–1.039 0.056 0.392–2.852 0.912

Endotracheal intubation
No 1.00
Yes 18.5 9.777–35.640 <0.001 0.117–4.590 0.739

Nasogastric tube
No 1.00
Yes 47.5 20.842–119.571 <0.001 3.361–36.966 <0.001

Urinary catheter
No 1.00
Yes 35.2 16.985–76.290 <0.001 0.379–16.424 0.342

(Continued)

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Table 4 (Continued).

OR Univariate Analysis Multivariate Analysis

95% CI p-value 95% CI p-value

Seizure
No 1.00
Yes 6.4 2.443–18.482 <0.001 0.660–24.484 0.131

Sepsis
No 1.00
Yes 16.8 5.539–67.661 <0.001 0.570–15.476 0.197

Urinary tract infection

No 1.00
Yes 18.2 5.208–96.311 <0.001 1.496–79.564 0.018

Heart failure
No 1.00
Yes 5.7 1.320–33.741 0.005 0.490–97.905 0.152

Arrhythmia
No 1.00
Yes 2.1 0.709–6.135 0.123 0.213–9.380 0.719

Table 5 Score For Predicting Post-Stroke Pneumonia Infection

Probability Score Case (n=108) Control (n=216) LHR+ 95% CI p-value
Categories
n % n %

Low 0-2 20 18.5 201 93.1 0.20 0.134–0.300 <0.001

Moderate 2.5-4 20 18.5 12 5.6 3.33 1.693–6.562 0.005
High 4.5–7.5 68 63.0 3 1.3 45.33 14.601–140.754 <0.001
Mean±SD 3.9±1.6 0.6±1.1 <0.001

surveillance in stroke patients who are likely to have Therefore this predicting score would cover all risk factors
pneumonia. and may decrease accuracy. Moreover, this score will still
Stroke patients in the age group 40–80 years, longer not be used in general practice so it could not be confirmed
length of stay, complications of cardiovascular disease and to assess in other populations.
urinary tract infection, or nasogastric tube use increase the
risk of developing pneumonia. It is possible that patients Conclusion
with a longer length of stay will have a longer time The score for predicting post-stroke pneumonia infection
exposed to pathogens in the hospital. Elderly people tend can be assessed as a screening program, but this study did
to be more at risk of developing pneumonia because their not yet use in practice. However, interpretation was lim-
immune system is weaker. The association with proce- ited by missing some important data that leads to potential
dures such as nasogastric tube is possibly related to severe risk factors to generate a score. We suggest that the next
illness leading to prolonged bed rest. study should require the prospective case control study for
This study is limited in that the data cannot collect the improving the quality of the data collection.
variables of NIHSS score, smoking and alcohol use history,
since this is a retrospective case controlled study and these Ethics Statement
data were not completely found in medical records, despite The authors wish to acknowledge the Research Ethics
another study providing this; these are associated risk fac- Committee of the Uttaradit Public Health Office, Uttaradit,
tors to develop post-stroke pneumonia statistically.12 Thailand, which has approved the following study which is to

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Dovepress Leangpanich et al

be carried out in compliance with the International guidelines 2. Who.int. [Internet]. Stroke, Cerebrovascular accident. WHO; 2018.
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public/@wcm/@hcm/@sta/documents/downloadable/ucm_474388.
(ICH-GCP). The authors receive the approval of granted pdf. Accessed September 8, 2018.
subject to this condition from the official affiliated name of 4. Westendorp W, Nederkoorn P, Vermeij J, Dijkgraaf M, de Beek D.
Post-stroke infection: a systematic review and meta-analysis. BMC
the institutional review board which approved this study are:
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The patient consent to review the medical records in this 5. Walter U, Knoblich R, Steinhagen V, Donat M, Benecke R, Kloth A.
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AHA.114.007843
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