Kamal, Ayeesha Kamran

Shaikh, Quratulain

English

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineJanuary 2014Can prophylactic antibiotics for aspiration improvestroke outcomes? The PANTHERIS trial.Ayeesha Kamran KamalAgha Khan University, ayeesha.kamal@aku.eduQuratulain ShaikhAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Neurology CommonsRecommended CitationKamal, A., Shaikh, Q. (2014). Can prophylactic antibiotics for aspiration improve stroke outcomes? The PANTHERIS trial.. JPMA.The Journal of the Pakistan Medical Association, 64(1), 98-99.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/346Can prophylactic antibiotics for aspiration improve strokeoutcomes? The PANTHERIS trialPages with reference to book, From 27 To 27 Quratulain Shaikh, Ayeesha Kamran Kamal  ( Stroke Service and Vascular Fellowship Program, InternationalCerebrovascular Translational Clinical Research Training Program (Fogarty International Center and National Institute ofNeurologic Disorders and Stroke), Aga Khan University Hospital, Karachi, Pakistan. ) Why is this important?Early mortality after ischaemic stroke is attributed largely to stroke associated pneumonia and isreported to be somewhere between 7-22%. Although some patients are at a higher risk of pneumoniafollowing stroke including those within the acute phase (9-36 hours.) and those with non-lacunar strokein the MCA territory. There is yet no evidence on the outcome of acute stroke if prophylactic antibiotictherapy is given to prevent aspiration pneumonia in high risk patients although some animal studieshave suggested benefits of the same. The Preventive Antibacterial Therapy in Acute Ischaemic Stroke(PANTHERIS) trial was done between May 2003 and July 2006 to observe the difference in outcomeof acute stroke if prophylactic antibiotic therapy was given.Who were the participants?This multicenter randomized double blind placebo controlled trial was conducted on high risk acutestroke patients in Germany. There were 40 patients in each arm of the study whereas 1 participantwithdrew from the treatment arm. The treatment arm was given 400mg Moxifloxacin daily IV for 5days while the placebo arm was given Riboflavin IV for 5 days. The participants were eligible if theyhad an acute (9-36 hours.) stroke in the MCA territory with NIHSS (National Institute of Health StrokeScale) score of >12 and were adults (>18 years).What were the outcomes?By intention-to-treat analysis 15% were in the treatment group vs. 32% of the placebo group (p=0.11).Treatment with Moxifloxacin led to a relative risk reduction of 46% in the intention-to-treat group vs.59% in the per protocol analyses. On an average pneumonia was diagnosed at 4.7±2.5 days after stroke.There was no difference in the requirement of mechanical ventilation within the two groups. CRPlevels in patients of the placebo group were significantly higher than in those of the treatment group.Survival did not vary significantly among the two groups by intention-to-treat analysis although thecumulative survival was significantly lower among those patients with infections vs. those without anyinfection. There was no significant difference in the neurological outcome at 6 months assessed via theBarthel Index. There was no significant difference in the incidence of adverse events among the twogroups.What were the conclusions?This trial confirms the poor outcome associated with infections after acute non-lacunar MCA stroke.Although the trial did not demonstrate any advantage of prophylactic antibiotic therapy for aspirationpneumonia regarding outcome or survival at 6 months, it does demonstrate the fact that infections post-stroke are a marker of poor outcome.What does this mean for clinicians practicing in Pakistan?In a country with limited resources, poor antibiotic restriction policies among health professionals andincreased rates and susceptibility to infections among stroke patients, this trial brings evidence to limitthe use of prophylactic antibiotics in acute stroke patients. Although general measures to reduce theincidence of infection including nutrition, aspiration prophylaxis measures and early rehabilitation maybe better and cost effective methods for prevention of aspiration pneumonia.Acknowledgement and Disclosure StatementThe International Cerebrovascular Translational Clinical Research and Training Program (ICT_CRT) atthe Aga Khan University is supported by funds from the Award Number D43TW008660 from theFogarty International Center and the National Institute of Neurologic Disorders and Stroke. The contentis solely the responsibility of the authors and does not necessarily represent the official views of theFogarty International Center or the National Institutes of Health.Suggested Reading1. Preventive Antibacterial Therapy in Acute Ischemic Stroke: A Randomized Controlled Trial. HendrikHarms, Konstantin Prass, Christian Meisel, Juliane Klehmet Witold Rogge, ChristophDrenckhahn, JosGöhler, Stefan Bereswill, Ulf Göbel, Klaus Dieter Wernecke,Tilo Wolf,Guy Arnold, Elke Halle, Hans-Dieter Volk, Ulrich Dirnagl, and Andreas Meisel, PLoS ONE 2008; 3: e2158.

Can prophylactic antibiotics for aspiration improve stroke outcomes? The PANTHERIS trial.

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Can prophylactic antibiotics for aspiration improve stroke outcomes? The PANTHERIS trial.

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