A Study On Relationship Between Procalcitonin Clearance And Early Neurological Deterioration In Stroke-associated Pneumonia Patients

Background and object Early neurological deterioration(END)is a common complication of acute stroke patient,and is closely related with increase of morbidity and mortality,longer hospitalization days and more medical costs.Until now,the mechanism of pathogenesis of END is unclear.There are no accurate and reliable early prediction indicators,but also the lack of effective prevention and treatment measures.Therefore,looking for the early clinical indicators that can predict the occurrence of END,in order to give timely intervention treatment to prevent the occurrence of END is urgent.At present,it is found that pneumonia is an independent predictor of neurological deterioration in stroke patients.Stroke associated pneumonia(SAP)is a common complication of acute stroke.Studies have shown that SAP is associated with poor prognosis of stroke.However,there are few reports about the relationship between stroke associated pneumonia and early neurological deterioration after acute stroke.Blood procalcitonin(PCT)is a new marker of inflammation,inflammatory reaction than the current commonly used indexes such as body temperature,leukocyte count,percentage of neutrophils,C protein(C-Reactive Protein,CRP),erythrocyte sedimentation rate has higher sensitivity and specificity.Therefore,in this study,we proposed by collecting a large number of clinical data of stroke patients,to analyze the relationship between SAP and END,and in SAP patients,continuous monitoring of serum PCT level,the calculation of PCT clearance rate(PCTc),and to analyze the relationship between PCT and PCTc and END,to assess the ability to use PCT and PCTc to predict the occurrence of END,and then clarify the value of treating pneumonia infection in stroke patients.Material and Method This study was a prospective observational study.The acute stroke patients consecutively admitted in the sixth district of Huanhu Hospital from November 2010 to October 2013 were collected.According to the diagnostic criteria of strokeassociated pneumonia [1] developed by Chinese experts consensus in 2010,the patients were divided into SAP group and non SAP group.END is defined as NIHSS score increased more than 4 points within 7 days of the occurace of acute ischemic stroke.All patients were subject to finish all clinical and labrotory examinations as well as imaging(CT or MRI),and record the medical history and basic situation as well as related risk factors,also evalue NIHSS score of patients.The patients were devided into SAP group and non SAP group.In SAPgroup the blood PCT were detected immediately after diagnosis,as well as at 24 h,48 h,and 72 h,and the rate of PCTc was calculated for a period of 24 h,48h,and 72 h.The PCTc of END and non END group were calculated for a period of 24 h,48h,and 72 h.The relationship between PCTc and END was calculated through statistical analysis.Result 1.A total of 2062 stroke patients were enrolled in this study.Among them,there were 363 cases(17.6%)with SAP,and 1699 cases(82.4%)without SAP.There was no significant difference between the two groups in gender composition,history of hypertension,hyperlipidemia,smoking history and so on(p>0.05,table 1).2.Compared with non SAP group,the age of SAP group was higher,the difference was statistically significant between the two groups(p<0.05,table 1).There was a significant difference between the two groups in terms of the proportion of diabetes mellitus,atrial fibrillation,tumor,NIHSS score at admission,myocardial infarction,and the presence of consciousness disorders and dysphagia.(p<0.05,table 3).3.78 END occurred in 363 cases of SAP group.235 END occurred in 1699 cases of non SAP group.The incidence of END was higher in the SAP group than in the non SAP group,and the difference was statistically significant(p<0.05,table 2).4.SAP is an independent risk factor for END in patients with acute stroke(OR = 0.054,95%CI 0.009~0.124,p<0.05,table 4).5.Comparison between END group and non END group: in 363 no SAP group patients,78 cases with END,and 285 cases with non END.The age and gender,history of hypertension,hyperlipidemia,smoking,previous stroke and the percentage of neutrophils,the level of APACHE II,HDL,LDL,TG and the blood pressure were no significant difference between the two groups of patients(p>0.05,table 1).Compared with the non END group,the proportion of patients with diabetes and WBC,CRP,TG,Fi,Hb A1 c levels and the NIHSS score in the END group were higher than those in non END group,the differences are significant(p<0.05,table 5).6.Comparison of PCT between END and non END group: compared with the non END group,the PCT of END group on admission,24 hours and 48 hours had no significant difference to non END group(p>0.05),but the PCT value on 72 hour is higher than that of non END group(p<0.05).For PCTc,there was no significant difference between the two groups(p>0.05)in both 24 and 48 h,and the PCTc in 72 h was significantly lower in the END group than in the non END group(p<0.05)(Table 6).7.Analysis of risk factors: there are obvious differences between the two groups of white blood cells,CRP,CHO,Fi and Hb A1 c,NIHSS scores on admission,history of diabetes and 72 hours PCT and PCTc levels.Including all of these factors in the multivariate linear regression equation analysis,doing Logistic regression analysis,the results showed that only PCTc in 72 h was closely related to END.The 72 h PCTc was an independent risk factor for END(OR = 0.008~0.128,95%CI,p<0.05),and the absolute value of PCT at 72 hours was not an independent risk factor for the occurrence of END(Table 7).8.ROC curve showed that the AUC for 72 h PCTc to predict END was 0.838(95%CI 0.751~0.924),and the sensitivity was about 77.14%,and the specificity was 87.5% when the cutoff value was about 32.2%(Table 8).Conclusion In this study,the gender,age,history of hypertension,diabetes history,atrial fibrillation,tumor history,NIHSS,TG,Fi,Hb A1 c and other factors of SAP groupand non SAP group were included to study the risk factors leading to SAP.The results show that in SAP group the patients had higher ratio of combination with diabetes,atrial fibrillation,tumor,myocardial infarction and higher NIHSS score on admission,and had more ratio of presence of disturbance of consciousness,dysphagia,and the statistical difference between the two groups was significant(p<0.05,table 1).The gender and age,history of hypertension,diabetes,hyperlipidemia,smoking and history of stroke,WBC,percentage of neutrophils,CRP,NIHSS,HDL,APACHE II,LDL,CHO,TG,Fi,Hb A1 c,systolic blood pressure and diastolic blood pressure and other factors in END and non END group was analized in order to study the cause and related risk factors of END.Firstly,single factor analysis of the related risk factors of the two groups was done,and the results showed that the ratio of combination with diabetes and the proportion of WBC,the level of CRP,TG,Fi and Hb A1 c,NIHSS scores on admission and 72 h,PCT and PCTc 72 h were significantly different between END and non END groups(p<0.05,table 1).Multiple regression analysis was further done with these significant different factors,and the results showed that only PCTc for 72 h were the independent risk factors for END of SAP patients,and CRP was not independent risk factors.Further ROC curve analysis showed that 72 h PCTc could predict the occurrence of early neurological deterioration to a certain extent,and the decrease of PCTc at the end of the 72 hours was a predictor of END(p<0.05).This study showed that END happened for SAP patients had no relation with the PCT at 24 h,48 h,but was related to PCT at 72 h according to the single factor analysis.But the multi factor analysis showed that PCT at 72 h was independent risk factors of END,while PCTc for 72 h was related to END of SAP patients.It showed that the initial infection of SAP patients might not lead to the occurrence of END,but poor control of infection could cause the happening of END.Monitoring the absolute value of PCT can not predict the occurrence of SAP in patients with END,and the introduction of PCTc is helpful to observe the dynamic changes of PCT,and the prediction of END.In addition,we can adjust the antibiotic treatment according to the change of PCTc.This suggests that we should beeffectively use antibiotics in patients with SAP according to the changes of PCTc to guide antibiotic therapy.