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ORIGINAL ARTICLE
Diagnosis and treatment of stroke associated pneumonia: Qualitative exploration of clinicians’ practice
1
Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MALAYSIA
2
Department of Pharmacy Practice, College of Clinical Pharmacy, Hodeidah University, Al Hodeidah, YEMEN
3
Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, JORDAN
4
Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, Wales, UK
5
Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, JORDAN
Online publication date: 2023-01-19
Publication date: 2023-03-01
Electron J Gen Med 2023;20(2):em454
KEYWORDS
ABSTRACT
Background:
Establishing and implementing a gold standard criteria for diagnosing and treating stroke-associated pneumonia (SAP) would have a significant positive impact on stroke outcomes and antibiotic stewardship. This study aimed to qualitatively explore current diagnostic and treatment practice for SAP among clinicians.
Methods:
A qualitative study was employed to conduct semi-structured interviews at the tertiary-care Jordan University Hospital. A purposive sampling technique was employed to recruit the participants, including respiratory consultants (n=3) and residents (n=9) practicing in the internal medicine wards and intensive care unit, where stroke patients are treated. The interviews were audio-recorded, transcribed verbatim, translated, and analyzed thematically using framework analysis.
Results:
Clinicians expressed their experiences, which were organized into two themes and eight emerged sub-themes: Terminology and diagnostic approach of SAP involved; no definite terminology, reliance on both clinical evidence and X-ray findings to decide, reliance on clinical evidence alone to suspect SAP and initiate empirical therapy, and SAP overdiagnosis. The treatment strategies include early treatment of SAP, treating SAP the same as CAP/HAP, predominant anaerobes coverage, and SAP overtreatment.
Conclusion:
Our findings show a wide range of physician-based diagnostic and treatment approaches for SAP, with clinical criteria serving as the main driver for antibiotic initiation. Standard validated algorithmic-based criteria need to be established and implemented.
Establishing and implementing a gold standard criteria for diagnosing and treating stroke-associated pneumonia (SAP) would have a significant positive impact on stroke outcomes and antibiotic stewardship. This study aimed to qualitatively explore current diagnostic and treatment practice for SAP among clinicians.
Methods:
A qualitative study was employed to conduct semi-structured interviews at the tertiary-care Jordan University Hospital. A purposive sampling technique was employed to recruit the participants, including respiratory consultants (n=3) and residents (n=9) practicing in the internal medicine wards and intensive care unit, where stroke patients are treated. The interviews were audio-recorded, transcribed verbatim, translated, and analyzed thematically using framework analysis.
Results:
Clinicians expressed their experiences, which were organized into two themes and eight emerged sub-themes: Terminology and diagnostic approach of SAP involved; no definite terminology, reliance on both clinical evidence and X-ray findings to decide, reliance on clinical evidence alone to suspect SAP and initiate empirical therapy, and SAP overdiagnosis. The treatment strategies include early treatment of SAP, treating SAP the same as CAP/HAP, predominant anaerobes coverage, and SAP overtreatment.
Conclusion:
Our findings show a wide range of physician-based diagnostic and treatment approaches for SAP, with clinical criteria serving as the main driver for antibiotic initiation. Standard validated algorithmic-based criteria need to be established and implemented.
REFERENCES (35)
1.
Wilson RD. Mortality and cost of pneumonia after stroke for different risk groups. J Stroke Cerebrovasc Dis. 2012;21(1):61-7. https://doi.org/10.1016/j.jstr... PMid:22225864 PMCid:PMC3255072.
2.
Kumar S, Selim MH, Caplan LR. Medical complications after stroke. Lancet Neurol. 2010;9(1):105-18. https://doi.org/10.1016/S1474-... PMid:20083041.
3.
Kalra L, Hodsoll J, Irshad S, Smithard D, Manawadu D. Association between nasogastric tubes, pneumonia, and clinical outcomes in acute stroke patients. Neurology. 2016;87(13):1352-9. https://doi.org/10.1212/WNL.00... PMid:27566745 PMCid:PMC5047037.
4.
Harms H, Hoffmann S, Malzahn U, Ohlraun S, Heuschmann P, Meisel A. Decision-making in the diagnosis and treatment of stroke-associated pneumonia. J Neurol Neurosurg Psychiatry. 2012;83(12):1225-30. https://doi.org/10.1136/jnnp-2... PMid:23024353.
5.
Ward K, Seymour J, Steier J, et al. Acute ischaemic hemispheric stroke is associated with impairment of reflex in addition to voluntary cough. Eur Respir J. 2010;36(6):1383-90. https://doi.org/10.1183/090319... PMid:20413536.
6.
Emsley HCA, Smith CJ, Gavin CM, et al. An early and sustained peripheral inflammatory response in acute ischaemic stroke: relationships with infection and atherosclerosis. J Neuroimmunol. 2003;139(1-2):93-101. https://doi.org/10.1016/S0165-... PMid:12799026.
7.
Ferdinand P, Roffe C. Hypoxia after stroke: A review of experimental and clinical evidence. Exp Transl Stroke Med. 2016;8:9. https://doi.org/10.1186/s13231... PMid:27980710 PMCid:PMC5143450.
8.
Esayag Y, Nikitin I, Bar-Ziv J, et al. Diagnostic value of chest radiographs in bedridden patients suspected of having pneumonia. Am J Med. 2010;123(1):88.e1-5. https://doi.org/10.1016/j.amjm... PMid:20102999.
9.
Cohen E, Mier A, Heywood P, Murphy K, Boultbee J, Guz A. Diaphragmatic movement in hemiplegic patients measured by ultrasonography. Thorax. 1994;49(9):890-5. https://doi.org/10.1136/thx.49... PMid:7940429 PMCid:PMC475186.
10.
Kishore AK, Vail A, Jeans AR, et al. Microbiological etiologies of pneumonia complicating stroke: A systematic review. Stroke. 2018;49(7):1602-9. https://doi.org/10.1161/STROKE... PMid:29915122.
11.
Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61-111.
12.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-67. https://doi.org/10.1164/rccm.2... PMid:31573350 PMCid:PMC6812437.
13.
Smith CJ, Kishore AK, Vail A, et al. Diagnosis of stroke-associated pneumonia: Recommendations from the pneumonia in stroke consensus group. Stroke. 2015;46(8):2335-40. https://doi.org/10.1161/STROKE... PMid:26111886.
14.
Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-32. https://doi.org/10.1016/j.ajic... PMid:18538699.
15.
Kishore AK, Jeans AR, Garau J, et al. Antibiotic treatment for pneumonia complicating stroke: Recommendations from the pneumonia in stroke consensus (PISCES) group. Eur Stroke J. 2019;4(4):318-28. https://doi.org/10.1177/239698... PMid:31903430 PMCid:PMC6921946.
16.
Kalra L, Hodsoll J, Irshad S, Smithard D, Manawadu D. Comparison of the diagnostic utility of physician-diagnosed with algorithm-defined stroke-associated pneumonia. J Neurol Neurosurg Psychiatry. 2016;87(11):1163-8. https://doi.org/10.1136/jnnp-2... PMid:27432801.
17.
Smith F. Health services research methods in pharmacy: Qualitative interviews. Int J Pharm Pract. 1998;6(2):97-108. https://doi.org/10.1111/j.2042....
18.
Kuper A, Reeves S, Levinson W. An introduction to reading and appraising qualitative research. BMJ. 2008;337:a288. https://doi.org/10.1136/bmj.a2... PMid:18687727.
19.
WHO. Process of translation and adaptation of instruments. World Health Organization. 2009. Available at: http://www.who.int/substance_a... (Accessed: 23 November 2022).
20.
Ritchie J, Lewis J, Nicholls CM, Ormston R. Qualitative research practice: A guide for social science students and researchers. Thousand Oaks, CA: SAGE; 2013.
21.
Kishore AK, Vail A, Chamorro A, et al. How is pneumonia diagnosed in clinical stroke research? A systematic review and meta-analysis. Stroke. 2015;46(5):1202-9. https://doi.org/10.1161/STROKE... PMid:25858238.
22.
Huang JY, Zhang DY, Yao Y, Xia QX, Fan QQ. Training in swallowing prevents aspiration pneumonia in stroke patients with dysphagia. J Int Med Res. 2006;34(3):303-6. https://doi.org/10.1177/147323... PMid:16866025.
23.
Hannawi Y, Hannawi B, Rao CPV, Suarez JI, Bershad EM. Stroke-associated pneumonia: major advances and obstacles. Cerebrovasc Dis. 2013;35(5):430-43. https://doi.org/10.1159/000350... PMid:23735757.
24.
Liu D-D, Chu S-F, Chen C, Yang P-F, Chen N-H, He X. Research progress in stroke-induced immunodepression syndrome (SIDS) and stroke-associated pneumonia (SAP). Neurochem Int. 2018;114:42-54. https://doi.org/10.1016/j.neui... PMid:29317279.
25.
Busti C, Agnelli G, Duranti M, Orlandi C, Marcucci M, Paciaroni M. Lung ultrasound in the diagnosis of stroke-associated pneumonia. Intern Emerg Med. 2014;9(2):173-8. https://doi.org/10.1007/s11739... PMid:22847729.
26.
Garin N, Marti C, Carballo S, et al. Rational use of CT-scan for the diagnosis of pneumonia: Comparative accuracy of different strategies. J Clin Med. 2019;8(4):514. https://doi.org/10.3390/jcm804... PMid:30991716 PMCid:PMC6518125.
27.
Kishore AK, Devaraj A, Vail A, et al. Use of pulmonary computed tomography for evaluating suspected stroke-associated pneumonia. J Stroke Cerebrovasc Dis. 2021;30(6):105757. https://doi.org/10.1016/j.jstr... PMid:33873077.
28.
Srinivasan A. Engaging hospitalists in antimicrobial stewardship: the CDC perspective. J Hosp Med. 2011;6(Suppl 1):S31-3. https://doi.org/10.1002/jhm.86... PMid:21225948.
29.
Cordoba G, Llor C. Overdiagnosis paradigm: not suitable for decreasing the overuse of antibiotics. BMJ Evid Based Med. 2019;24(5):174-6. https://doi.org/10.1136/bmjebm... PMid:30745411 PMCid:PMC6837244.
30.
NICE Guidelines. Pneumonia: Diagnosis and management of community- and hospital-acquired pneumonia in adults. NICE. 2014. Available at: http://www.nice.org.uk/%0Aguid... (Accessed: 23 November 2022).
31.
National Collaborating Centre for Chronic Conditions (UK). Stroke: National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). London: Royal College of Physicians (UK); 2008. PMID:21698846.
32.
Kalra L, Irshad S, Hodsoll J, et al. Prophylactic antibiotics after acute stroke for reducing pneumonia in patients with dysphagia (STROKE-INF): A prospective, cluster-randomised, open-label, masked endpoint, controlled clinical trial. Lancet. 2015;386(10006):1835-44. https://doi.org/10.1016/S0140-... PMid:26343840.
33.
Westendorp WF, Vermeij J-D, Zock E, et al. The preventive antibiotics in stroke study (PASS): A pragmatic randomised open-label masked endpoint clinical trial. Lancet. 2015;385(9977):1519-26. https://doi.org/10.1016/S0140-... PMid:25612858.
34.
Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: A prospective study. Chest. 1999;115(1):178-83. https://doi.org/10.1378/chest.... PMid:9925081.
35.
El-Solh AA, Pietrantoni C, Bhat A, et al. Microbiology of severe aspiration pneumonia in institutionalized elderly. Am J Respir Crit Care Med. 2003;167(12):1650-4. https://doi.org/10.1164/rccm.2... PMid:12689848.
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