BALTIMORE – Patients who acquired a nosocomial infection during their hospital stay for status epilepticus had five times greater odds of dying than did noninfected patients in a single-center, observational cohort study.
The infections, most of which involved the respiratory tract, also were associated with having treatment-refractory status epilepticus, a longer ICU stay, and a worse overall outcome, Dr. Raoul Sutter said at the annual meeting of the American Epilepsy Society.
Dr. Raoul Sutter
"Our findings underscore the importance of close observation of these patents and rigorous adherence to the prevention guidelines for hospital-acquired infections, as well as the urgent need for early diagnosis and treatment of status epilepticus and infection-related complications, especially in the first 3 days," said Dr. Sutter, who conducted the research while he was a member of the departments of neurology and intensive care medicine at University Hospital Basel (Switzerland). He is now a research fellow in the neurosciences critical care unit at Johns Hopkins University, Baltimore.
Dr. Sutter and his coinvestigators could not identify a reliable one-time marker for indicating the presence of infection at the onset of status.
He and his colleagues studied a cohort of 160 patients hospitalized for status epilepticus at University Hospital Basel (Switzerland) during a 5-year period. Their median age was 65 years (range 17-91 years) and more than half (55%) required mechanical ventilation.
About 22% of the cohort developed an infection during the first 3 days of hospital stay. Patients with an infection had a significantly longer ICU stay (mean of 11 days vs. 6 days) and five times greater odds of dying than did patients without infections, according to the study’s findings, which Dr. Sutter presented in two posters at the meeting.
Most of the infections involved the respiratory tract, with half being ventilator-associated pneumonias. Compared with patients without infections, patients with respiratory tract infections had a significantly longer duration of status (mean 7 vs. 2 days) and a longer ICU stay (mean 11 vs. 7 days). These infections also were associated with a significant increase in the odds of developing refractory status (odds ratio, 5.4) and dying (OR, 4). A majority (59%) with refractory status and an infection died (59%).
"Time of onset of infectious complications during status epilepticus was a critical element in outcome," Dr. Sutter said in an interview. "Patients who had a confirmed infection before admission had no significant increase in the risk of refractory status or death."
Early detection and treatment of infectious complications may mitigate their deleterious effects on these critically ill patients. Because early detection in this setting can be challenging, biomarkers could be useful for their diagnosis, he said.
In a search for a biomarker to indicate the presence of infection at the onset of status, the investigators found that serum procalcitonin, C-reactive protein (CRP), or white blood cell count did not accurately predict an oncoming hospital-acquired infection. However, a serial increase in CRP and white blood cell count over 3 days after status onset was significantly associated with infection.
Low levels tended to rule out infections. The negative predictive value of a low CRP over 3 days was 97%, but specificity remained low and did not improve despite using several cut-off values.
"Right now, we have identified the problem and deleterious impact of infections in status epilepticus, but we don’t really have an ideal solution to it," Dr. Sutter said.
The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America have issued practice recommendations to reduce the risk of ventilator-associated pneumonia. In addition to minimizing mechanical ventilation, the recommendations suggest measures to reduce colonization of the aerodigestive tract and prevent aspiration.
Selective digestive tract decontamination and selective oropharyngeal decontamination have recently been reported to reduce the mortality rate of critical ill patients by an estimated 3.5% and 2.9%, respectively, Dr. Sutter said.
"Despite the potential benefits described, selective decontamination of the digestive tract has not been largely adopted, most likely because of major concerns about promoting the growth of resistant bacteria," he said. "However, in light of the association of respiratory tract infections and worse outcomes that we observed, the benefit may outweigh this risk by far."
Dr. Sutter reported having no financial disclosures.