Published online Oct 19, 2026. doi: 10.5498/wjp.121968
Revised: July 4, 2026
Accepted: August 5, 2026
Published online: October 19, 2026
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Stroke-associated pneumonia (SAP) is the most common infectious complication after acute cerebral infarction, occurring in 7%-38% of hospitalized stroke patients and independently associated with higher mortality rates and extended hospital stays. Post-stroke depression (PSD) is present in approximately 30%-50% of stroke survivors and may additionally impair immunity, decrease compliance with rehabilitation, and worsen the clinical trajectory of SAP. However, the association of concomitant PSD with SAP outcomes and the determinants of poor prognosis in this population are not well defined.
To investigate the impact of PSD on outcomes in patients with SAP and identify independent predictors of poor prognosis in patients with SAP and comorbid depression.
This study included 186 patients with SAP after acute cerebral infarction who were admitted to the Department of Neurological Intensive Rehabilitation, Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine, Hebei Province, China, between December 2014 and December 2025. Patients with a recorded Hamilton Depression Rating Scale score 2 weeks after stroke were divided into a depression group (n = 92) and non-depression group (n = 94). Overall data were gathered, including demographics, comorbidities, stroke characteristics, SAP severity indices, treatment modalities (including traditional Chinese medicine intervention like warm moxibustion therapy), laboratory biomarkers [procalcitonin, C-reactive protein, albumin, lymphocyte count, serum brain-derived neurotrophic factor (BDNF), interleukin-6 and cortisol] and outcome measures. Pulmonary infection resolution time, total hospital stays, mechanical ventilation duration, 28-day mortality, and functional outcomes measured by the modified Rankin Scale (mRS) were primary endpoints. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of an adverse prognosis.
Comorbid PSD was present in 92 (49.5%) of the 186 SAP patients. Patients in the depression group had significantly worse pulmonary infection resolution time (16.8 ± 4.5 days vs 11.2 ± 3.2 days, P < 0.001), longer hospitalization stay (28.5 ± 7.8 days vs 19.3 ± 5.6 days, P < 0.001), longer duration on mechanical ventilation (8.5 vs 5.2 days, P < 0.001), higher mortality within the following 28-day timeframe (18.5% vs 7.4%, P = 0.024), and worse functional outcomes defined by an mRS ≥ 3 at discharge (P = 0.001). Seven independent adverse prognosis predictors were identified by multivariable logistic regression modeling: Comorbid PSD [odds ratio (OR) = 3.12, 95% confidence interval (95%CI): 1.85-5.26, P < 0.001], Acute Physiology and Chronic Health Evaluation II score ≥ 18 (OR = 3.45, 95%CI: 1.92-6.20, P < 0.001), serum albumin < 30 g/L (OR = 2.78, 95%CI: 1.55-4.98, P = 0.001), mechanical ventilation > 7 days (OR = 2.65, 95%CI: 1.48-4.75, P = 0.001), multi-drug resistant organism infection (OR = 2.52, 95%CI: 1.42-4.47, P = 0.002), BDNF < 14.5 ng/mL (OR = 2.35, 95%CI: 1.28-4.32, P = 0.006), and age ≥ 75 years (OR = 1.98, 95%CI: 1.15-3.41, P = 0.014). The area under the curve was 0.91 (95%CI: 0.86-0.96), and the combined predictive model had a sensitivity of 84.6% and a specificity of 87.3%. Patients that received integrated traditional Chinese and Western medicine treatment, including warm moxibustion, had a faster time of infection resolution (13.2 ± 3.8 days vs 15.5 ± 4.5 days, P = 0.012) and improved functional outcomes compared with controls.
Comorbid PSD further worsened the clinical outcomes of patients with SAP with a longer time to infection resolution, longer length of stay, increased mortality, and poor functional recovery. A predictive model based on the combination of depression status, disease severity, nutritional indicators and serum biomarkers had high diagnostic accuracy in identifying at-risk patients. Warm moxibustion, which is the simple application of heat and acupuncture point stimulation, improved time of infection resolution and functional outcomes. However, approaches that integrate traditional Chinese medicine and similar Western medicine concordantly may be more efficacious. These findings support the rationale for early identification and management of SAD in affected patients with SAP as a means to improve outcomes.
Core Tip: This retrospective study of 186 patients with stroke-associated pneumonia (SAP) demonstrates that co-morbid post-stroke depression is highly prevalent (approximately 50% of SAP) and an independent predictor of adverse prognosis, including markedly longer time to resolution of infection, prolonged hospital stays, worse functional recovery at discharge, and higher 28-day mortality. A robust seven-variable predictor model incorporating depression status, disease severity indices (Acute Physiology and Chronic Health Evaluation II), nutritional biomarkers (albumin), infectious parameters (multi-drug resistant organism status), neurotrophic factors (brain-derived neurotrophic factor), mechanical ventilation duration, and age, yielded excellent discriminative power with an area under the curve of 0.91, representing a clinically actionable framework for early identification of high-risk SAP patients. These findings suggest that routine depression screening may be important in SAP management, and integrated traditional Chinese and Western medicine approaches, especially warm moxibustion, may have beneficial effects.