Review question

Does preventive antibiotic therapy in people with acute stroke reduce the risk of dependency and death at follow-up, and does it reduce the infection rate?

Background

Stroke is the main cause of disability in high-income countries and ranks second as a cause of death worldwide. It is often followed by complications, especially infections, which occur in approximately 30% of people who have had a stroke. The occurrence of an infection may adversely affect clinical outcome after stroke. Preventive antibiotic therapy may reduce the number of infections, thereby improving stroke outcome.

Search date

This review is current to May 2017.

Study characteristics

We included eight studies on preventive antibiotic therapy, with a total of 4488 people with stroke: 2230 participants were randomised to preventive antibiotic therapy, and 2258 to control. The mean age of participants in the preventive antibiotics group was 74.2 years, and in the control group 74.8 years. In both groups, the percentage of men was 52%. Study interventions differed in all eight studies; in two studies, trialists selected the (type of) antibiotic according to local antibiotic policy, with the aim of treating pneumonia.

Key results

Preventive antibiotic treatment did not reduce the risk of dependency or death.

However, preventive antibiotic therapy did significantly reduce the occurrence of ‘overall’ infections from 26% to 19%. Regarding type of infection, findings were highly significant for urinary tract infections (4% vs 10%) but showed no effect on pneumonia (10% vs 11%).

No major side effects of preventive antibiotic therapy were reported.

Quality of the evidence

It has become possible to draw first ‘overall’ conclusions on the net effect of preventive antibiotic therapy in stroke; however, the decision of whether to use preventive antibiotic therapy in acute stroke should be reached with care. Studies were heterogeneous, and despite the large numbers of participants, results from a total of eight studies are limited. In two of these studies, risk of bias was considered to be high for three out of six criteria. Overall, reviewers considered the quality of evidence for the main outcomes of this review – looking at ‘any’ preventive antibiotic therapy, in ‘any’ dose, at any length of treatment – as high to moderate.