Original Article
Acute Ischemic Stroke and Infections

https://doi.org/10.1016/j.jstrokecerebrovasdis.2009.09.011Get rights and content

We present an overview of multiple infections in relation to acute ischemic stroke and the therapeutic options available. Conditions that are a direct cause of stroke (infectious endocarditis, meningoencephalitides, and human immunodeficiency virus infection), the pathophysiologic mechanism responsible for stroke, and treatment dilemmas are presented. Independently or in conjunction with conventional risk factors, chronic and acute infections can trigger an acute ischemic stroke through an accelerated process of atherosclerosis and immunohematologic alterations. Acute ischemic stroke has a negative impact on the antibacterial immune response, leading to stroke-induced immunodepression and infections, the most common poststroke medical complications. Poststroke infections are independent predictors of poor outcome. Antibiotic trials for poststroke infection prevention are reviewed. Although antibiotic prophylaxis is not the standard of care in acute stroke, current guidelines support prompt treatment of stroke-related infections.

Section snippets

Infectious Endocarditis

Infectious endocarditis is an endovascular, microbial infection of the intracardiac structures (native or prosthetic) and of the large intrathoracic vessels1 resulting from a complex interaction among the microbial agent and the matrix molecules and platelets on the damaged endocardial surface. Turbulent flow, produced by congenital or acquired cardiac disease, damages the endothelium, predisposing to platelet and fibrin deposition. The resultant vegetation of an initially nonbacterial

Meningoencephalitides Complicated With Infectious Vasculitis

Cerebral infarction is a complication of perinatal and childhood meningitis (which is almost exclusively bacterial in immunocompetent children), with a reported frequency between 10%19 and 37%.20 The etiologic agents differ depending on patient age, climate, geography, and socioeconomic status. In the neonatal period (age 0-28 days), bacterial meningitis prevails over other etiologies, including group B streptococci, enteric gram-negative rods (Enterobacter cloacae, Escherichia coli, Salmonella

Chronic Infections, Inflammation, and Atherosclerosis

Only 50% of cases of coronary artery disease and carotid arteriosclerosis can be explained by the usual risk factors of age, sex, hypertension, hyperlipidemia, smoking, and diabetes. Recently, it has been shown that C-reactive protein level is a stronger predictor of cardiovascular events than low-density lipoprotein cholesterol level.38 Chronic infection and the subsequent chronic inflammatory processes manifested by elevated levels of plasma fibrinogen, C-reactive protein, interleukin-6, and

Acute Infections Preceding Stroke

The overall reported prevalence of acute infections ranges from 18% to 40% in the month preceding the onset of acute ischemic stroke and from 10% to 40% in the week preceding stroke.39 The estimated relative risk of stroke after infection in the preceding month is reportedly between 1.8 (95% confidence interval [CI] = 0.6-3.6)51 and 9.0 (95% CI = 2.2-80.0).52 The risk of stroke seems to peak within 1 week of an acute infection, likely secondary to multiple immunohematologic alterations leading

Stroke-Associated Infections

Infections are the most common medical complications occurring during the admission of patients with stroke and are the leading cause of death in patients who have sustained stroke. The prevalence of chest infections is reportedly 11.2%-22%, and that of urinary tract infection is 16%-24%.62, 63 Poststroke pneumonia can result from invasive maneuvers, such as feeding tube placement,64 or aspiration of nasopharyngeal secretions caused by a decreased level of consciousness and reduced bulbar

Clinical Impact of Poststroke Infection

Stroke-related infections, particularly pneumonia, have been independently associated with poor stroke outcome and increased mortality.73, 74 Infection-related effects, such as fever,75 hypotension,76 and hypoxia,77 are expected to impair neuronal survival in the ischemic penumbra, and are recognized as additional predictors of poor outcome in stroke. Thus, prophylactic antimicrobial treatment is anticipated to reduce the stroke-related infection rate and improve stroke outcome. However, the

Conclusion and Future Considerations

Despite advances in diagnosis and treatment, infectious endocarditis remains a life-threatening infection with a significant risk for stroke. However, recently published American Heart Association guidelines on preventing infectious endocarditis support antibiotic prophylaxis for dental procedures involving soft tissue manipulation and mucosal perforation. For procedures involving the respiratory tract, infected skin, or musculoskeletal system, antibiotic prophylaxis is recommended only in

Acknowledgment

We thank Paul H. Dressel, BFA, for preparing the illustrations and Debra J. Zimmer, AAS CMA-A, for providing editorial assistance.

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    Dr. Ionita has no disclosure information to report. Dr. Siddiqui has received a research grant from the University at Buffalo; is a consultant to Codman/Cordis, Concentric Medical, ev3, and Micrus Endovascular; serves on speakers' bureaus for Cordis and Genentech; and has received honoraria from Genentech, Neocure, an American Association of Neurological Surgeons' course, and an Emergency Medicine Conference and from Cordis for training other neurointerventionists. Dr. Levy receives research grant support, other research support (devices), and honoraria from Boston Scientific and research support from Micrus Endovascular and ev3; has ownership interests in Intratech Medical Ltd and Mynx/Access Closure; serves as a consultant on the board of Scientific Advisors to Cordis Neurovascular; serves as a consultant for Micrus Endovascular, ev3, and TheraSyn Sensors; and receives fees for carotid stent training from Abbott Vascular and ev3. Dr. Levy receives no consulting salary arrangements; all consulting is per project and/or per hour. Dr. Hopkins receives research support from Toshiba; serves as a consultant to Abbott, Boston Scientific, Cordis, Micrus, and WL Gore; has a financial interest in AccessClosure, Boston Scientific, and Micrus; serves as a board member or trustee or holds an officer position in AccessClosure and Micrus; and receives honoraria from Bard, Boston Scientific, and Cordis. Dr. Snyder has no disclosure information to report. Dr. Gibbons is a site principal investigator and receives research support from Medtronic.

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