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Risk Score to Predict Hospital-Acquired

Pneumonia After Spontaneous Intracerebral
Hemorrhage

Article in Stroke July 2014

DOI: 10.1161/STROKEAHA.114.005023 Source: PubMed

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 Risk Score to Predict Hospital-Acquired Pneumonia After
Spontaneous Intracerebral Hemorrhage
Ruijun Ji, MD, PhD; Haipeng Shen, PhD; Yuesong Pan, PhD; Wanliang Du, MD, PhD;
Penglian Wang, MD, PhD; Gaifen Liu, MD, PhD; Yilong Wang, MD, PhD; Hao Li, PhD;
Xingquan Zhao, MD, PhD; Yongjun Wang, MD;
on behalf of the China National Stroke Registry investigators

Background and PurposeWe aimed to develop a risk score (intracerebral hemorrhageassociated pneumonia score, ICH-
APS) for predicting hospital-acquired stroke-associated pneumonia (SAP) after ICH.
MethodsThe ICH-APS was developed based on the China National Stroke Registry (CNSR), in which eligible patients
were randomly divided into derivation (60%) and validation (40%) cohorts. Variables routinely collected at presentation
were used for predicting SAP after ICH. For testing the added value of hematoma volume measure, we separately
developed 2 models with (ICH-APS-B) and without (ICH-APS-A) hematoma volume included. Multivariable logistic
regression was performed to identify independent predictors. The area under the receiver operating characteristic curve
(AUROC), HosmerLemeshow goodness-of-fit test, and integrated discrimination index were used to assess model
discrimination, calibration, and reclassification, respectively.
ResultsThe SAP was 16.4% and 17.7% in the overall derivation (n=2998) and validation (n=2000) cohorts, respectively.
A 23-point ICH-APS-A was developed based on a set of predictors and showed good discrimination in the overall
derivation (AUROC, 0.75; 95% confidence interval, 0.720.77) and validation (AUROC, 0.76; 95% confidence interval,
0.710.79) cohorts. The ICH-APS-A was more sensitive for patients with length of stay >48 hours (AUROC, 0.78; 95%
confidence interval, 0.750.81) than those with length of stay <48 hours (AUROC, 0.64; 95% confidence interval, 0.55
0.73). The ICH-APS-A was well calibrated (HosmerLemeshow test) in the derivation (P=0.20) and validation (P=0.66)
cohorts. Similarly, a 26-point ICH-APS-B was established. The ICH-APS-A and ICH-APS-B were not significantly
different in discrimination and reclassification for SAP after ICH.
ConclusionThe ICH-APSs are valid risk scores for predicting SAP after ICH, especially for patients with length of stay
>48 hours.(Stroke. 2014;45:2620-2628.)
Key Words: cerebral hemorrhage forecasting pneumonia

S pontaneous intracerebral hemorrhage (ICH) accounts for

10% to 15% of all strokes and is one of the leading causes
of stroke-related mortality and morbidity worldwide. Patients
with ICH are generally at risk of developing stroke-associated
pneumonia (SAP) during acute hospitalization. Evidence has
shown that SAP not only increases the length of hospital stay
(LOS) and medical cost1,2 but also is an important risk factor
of mortality and morbidity after acute stroke.3,4
Several risk factors for SAP have been identified, such as
older age,412 male sex,5,6,10,11,13 current smoking,12 diabetes mel-
litus,6 hypertension,14 atrial fibrillation,7,10,12 congestive heart
failure,7,12,13,15 chronic obstructive pulmonary disease,8,1214
preexisting dependency,8,12,13,16 stroke severity,5,6,8,12,17,18 dys-
phagia,812,14,1820 and blood glucose.12 Meanwhile, based on
these risk factors, a few risk models have been developed for
SAP after acute ischemic stroke.812 Currently, no valid scor-
ing system is available for predicting SAP after ICH in routine
clinical practice or clinical trial. We hypothesized that there
might be some common grounds for the development of pneu-
monia after acute ischemic stroke and ICH, and those predic-
tors for SAP after acute ischemic stroke might also be useful
for predicting SAP after ICH. For clinical practice, an effec-
tive risk-stratification and prognostic model for SAP after
ICH would be helpful to identify vulnerable patients, allocate
relevant medical resources, and implement tailored preventive
strategies. In addition, for clinical trial, it could be used in
nonrandomized studies to control for case-mix variation and
in controlled studies as a selection criterion.

Received February 5, 2014; accepted June 16, 2014.

From the Tiantan Comprehensive Stroke Center, Tiantan Hospital, Capital Medical University, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang,
H.L., X.Z., Yongjun Wang); China National Clinical Research Center for Neurological Diseases, Beijing, China (R.J., Y.P., W.D., P.W., G.L., Yilong Wang,
H.L., X.Z., Yongjun Wang); and Department of Statistics and Operation Research, University of North Carolina, Chapel Hill (H.S.).
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.
114.005023/-/DC1.
Correspondence to Yongjun Wang, MD, Tiantan Comprehensive Stroke Center, Beijing Tiantan Hospital, Capital Medical University, No. 6 Tiantan Xili,
Dongcheng District, Beijing 100050, China. E-mail yongjunwang1962@gmail.com
2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.114.005023

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