Purpose - The microbiological etiology of pneumonia complicating stroke is poorly characterized. In this second Pneumonia In Stroke ConsEnsuS (PISCES-2) statement, we propose a standardized approach to empirical antibiotic therapy in pneumonia complicating stroke, based on likely microbiological etiology, to improve antibiotic stewardship.
Methods - Systematic literature searches of multiple databases were undertaken. An evidence review and a round of consensus consultation was completed prior to a final multi-disciplinary consensus meeting in September 2017, held in Barcelona, Spain. Consensus was approached using a modified Delphi technique and defined a priori as 75% agreement between the consensus group members..
Findings - No randomized trials to guide antibiotic treatment of pneumonia complicating stroke were identified. Consensus was reached for the following: (1) Stroke-associated pneumonia (SAP) may be caused by organisms associated with either community-acquired or hospital-acquired pneumonia (CAP or HAP); (2) Treatment for early SAP (<72 h of stroke onset) should cover CAP organisms; (3) Treatment for late SAP (≥72 h and within 7 d of stroke onset) should cover CAP organisms plus coliforms +/- Pseudomonas spp. if risk factors; (4) No additional antimicrobial cover is required for patients with dysphagia or aspiration; (5) Pneumonia occurring after 7 d from stroke onset should be treated as for HAP; (6) Treatment should continue for at least 7 d for each of these scenarios.
Discussion- Consensus recommendations for antibiotic treatment of the spectrum of pneumonia complicating stroke are proposed. However there was limited evidence available to formulate consensus on choice of specific antibiotic class for pneumonia complicating stroke.
Conclusion- Further studies are required to inform evidence-based treatment of SAP including randomized trials of antibiotics and validation of candidate biomarkers.