Infection is a common complication in patients with acute and chronic stroke. Once they occur, if not effectively controlled in a timely manner, they may not only aggravate cardiorespiratory and renal functions, but also affect the progress of recovery and, in severe cases, may lead to the patient’s death.
In terms of preferred sites, the respiratory system (especially the lungs) is always high on the list, followed closely by the urinary system, then the digestive system, skin, blood, bones, muscles and brain.
In terms of causes, aspiration pneumonia due to consciousness or swallowing dysfunction is the most common. Decreased resistance, malnutrition, various invasive placements (e.g. oxygen, gastric, urinary, deep venous cannulae, etc.), prolonged bed rest, reduced active movement of the limbs, inpatient environment, antibiotic abuse, and depression are also common and often coexisting contributing factors.
This determines that the control strategy for such patients is not just a simple matter of how to choose antibiotics, but a complex issue that requires comprehensive consideration and a comprehensive approach. The following three phenomena are common phenomena that the author has often experienced or heard and witnessed in his long-term clinical work.
1, a one-sided equation between antibiotic use and infection control. Many clinicians and families immediately associate the use of antibiotics with the appearance of signs of infection in patients, believing that infection cannot be controlled without antibiotics.
2, one-sidedly regard the use of antibiotics as the only or all means of infection control.
3.Irrational use of antibiotics. Or too early, or too late; or lack of specificity; or too short, or too long; or excessive reliance on experience, or unchanging use from beginning to end.
According to the above phenomenon, the author talks about his own experience based on literature reading and personal experience.
1, control of infection does not necessarily require the use of antibiotics.
This mainly involves the timing of the use of the latter.
First of all, from the basic pathophysiology of infection, any infection is essentially a pathological phenomenon that can occur only under the dual action of endogenous and exogenous factors. Therefore, if a stroke patient’s infection symptoms are not serious, and the previous good health, the internal environment is basically stable, it is completely possible to suspend or even not to use antibiotics. For a patient in a stroke coma, even a lung infection with mild symptoms should be given high priority and antibiotics should be administered sooner rather than later.
Secondly, from the nature of the infection, if the external causes are not strong enough (such as the amount of bacteria is not large, not many strains are not toxic, and the site is not deep), it is also perfectly possible to control the infection by means of strengthening the internal causes (correcting malnutrition, improving local blood circulation, promoting discharge of secretions, increasing active and passive movement, etc.).
Therefore, the use and timing of antibiotics must be individualized. Although there are various guidelines for diagnosis and treatment, any guidelines are framework, clinicians cannot copy the guidelines, they must fully understand and evaluate the functional status of each organ of the patient, weigh the near and long-term interests of the patient, and make the decision of antibiotic use carefully.
2. Antibiotic use is not the only means of infection control.
The reason why many clinical infections are poorly controlled is not the wrong choice of antibiotics, but over-reliance on the use of antibiotics.
In the case of pulmonary infections, for example, airway management may be more critical and important than antibiotic use! Turning and patting the back, regular position changes, airway humidification, timely fluid replacement and suctioning, correction of imbalanced internal environment, improvement of poor nutritional status, regular oral cleaning, and changing oxygen tubes are all non-antibiotic means of infection control. For patients with urinary tract infections, regular bladder flushing, alkalinization of urine, timely treatment of the enlarged prostate in men, cleaning of urethral stones, and ensuring adequate urine output are also very effective infection control tools.
Therefore, for patients who must use antibiotics for stroke co-infection, they must use antibiotics on top of other non-antibiotic means according to the degree, location, nature and general physical condition of the infection in order to effectively control the infection.
3, the use of antibiotics must be scientific and reasonable.
Once you decide to use antibiotics to control the infection, you must follow the scientific and reasonable principles.
First of all, the site and nature of the infection must be identified as soon as possible according to the symptoms and signs, combined with some basic examinations (such as chest X-ray, ultrasound, blood and urine routine, body fluids and secretion culture, etc.), rather than hastily and hastily using antibiotics.
Generally speaking, most infections can be inferred from symptoms and signs, and theoretically, if the infection is severe and failure to administer antibiotics in a timely manner may induce serious consequences, certain broad-spectrum antibiotics may be used empirically for “fire suppression”. However, in order to follow up on the need for “precision”, it is still necessary to complete the above-mentioned tests as soon as possible, especially the culture of body fluids and secretions.
But there are always clinical surprises, and it is these surprises that sharpen the legendary doctors who continue to be celebrated in the jungle.
Many veteran physicians have had the experience of treating “nameless swelling”-like infections where no foci or causative organisms could be found. Here, I will not analyze their causes, but only talk about my personal experience with such patients.
Usually, as long as the conditions allow, such patients should do the tests should be done, but the results are often like everything and nothing; family members and doctors are very anxious, but they can not do anything. At this time, the urge to use antibiotics is the strongest, and the easiest way to comfort the inner anxiety.
However, experience has taught us that the most important thing we need at this time is calmness!
Only if the nature of the infection cannot be determined after repeated culture of various body fluids, secretions, biopsies and other tissues, and the clinical signs tend to support the infection of the causative organism, should antibiotics be used for diagnostic treatment. The antibiotics at this point in time, taking into account the dual mission of diagnosis and treatment, as much as possible to send the “tough role” on the field: the antibacterial spectrum must be broad, the level must be “high”, the dose must be large enough, the course of treatment must be long enough, otherwise it is very likely to appear incestuous The more embarrassing situation, neither to achieve the purpose of diagnosis, but also to complete the mission of treatment!
Second, the choice of antibiotics should be reasonable. As mentioned in various guidelines for diagnosis and treatment related to infections, early empirical selection of antibiotics for infections with unspecified causative agents can begin with a rough classification of the infection, such as classifying pneumonia as community-acquired, nosocomial-acquired, ventilator-associated, inhalational, etc., and then follow the guidelines for antibiotic selection.
According to the latest research, short-term antibiotic use is roughly the same as long-term use in terms of relapse rate, remission rate, and mortality, but has significant advantages in terms of side effects and costs. However, short-term antibiotics should not be used “arbitrarily”, and the decision to continue or change the regimen should be made carefully based on the degree of infection, the speed of symptom relief, relevant inflammatory indicators (e.g., blood picture, chest X-ray, serum calcitonin level, etc.), and the functional status of other organs.