Co-infection and ICU-acquired infection in COVID-19 ICU patients: a secondary analysis of the UNITE-COVID data set

Abstract

Background The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients. Methods This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson’s Chi-squared and continuous variables by Mann–Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the “full” matching method. Results Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO. Conclusions In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021). Graphical abstract

Use of Electronic Clinical Data to Track Incidence and Mortality for SARS-CoV-2–Associated Sepsis

“…While distinguishing pure viral sepsis from bacterial sepsis related to a non–SARS-CoV-2 coinfection or superinfection is challenging with an EHR-based approach, only a minority of patients with SARS-CoV-2–associated sepsis had positive blood or sputum cultures identified, supporting SARS-CoV-2 itself as the primary driver of sepsis in most cases. Numerous prior studies have demonstrated that bacterial coinfections are the exception rather than the norm for patients hospitalized with COVID-19 . However, these patients are at high risk for nosocomial bacterial infections, consistent with our observation that many more patients with SARS-CoV-2–associated sepsis had positive cultures across their entire hospitalizations …”

Risk factors, outcomes, and epidemiological and etiological study of hospitalized COVID-19 patients with bacterial co-infection and secondary infections

“…Here, we reported 16.3% (95%CI 13.0–21.9%) of COVID-19 patients with bacterial co-infection, which was slightly higher than the previously reported bacterial co-infection rate among mixed COVID population with a high degree of heterogeneity [ 7 , 8 , 16 , 17 ]. In a meta-analysis, bacterial co-infection and secondary infections were identified in 3.5% and 14.3% of patients respectively [ 18 ].…”

Relationship between corticosteroid use and incidence of ventilator-associated pneumonia in COVID-19 patients: a retrospective multicenter study

“…To date, there is no prospective interventional study that evaluated the impact of corticosteroid use on the incidence of VAP, as the RECOVERY study itself did not include it as an outcome. However, there is a growing body of evidence in the literature pointing out the increased risk of developing VAP in COVID-19 patients treated with corticosteroids [ 16 – 19 , 27 , 28 ].…”