Co-infection in critically ill patients with COVID-19: An observational cohort study from England

Abstract

Objective: To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England. Methods: A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 hours following hospital admission, corresponding to community and hospital-acquired co-infections. Results: Of 254 patients studied (median age 59 years (IQR 49-69); 64.6% male), 139 clinically significant organisms were identified from 83(32.7%) patients. Bacterial co-infections were identified within 48 hours of admission in 14(5.5%) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli. The co-infection rate >48 hours after admission was 27/1000 person-days (95% CI 21.3-34.1). Patients with co-infections were more likely to die in ICU (crude OR 1.78,95% CI 1.03-3.08, p=0.04) compared to those without co-infections. Conclusion: We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay.

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

“…Since complicating bacterial infections are infrequent in the early hospitalisation period of COVID-19, this recognised concern in relation to the use of tocilizumab would be lessened with earlier use. 20 On the basis of the ISARIC4C database, approximately 49% of hospitalised COVID-19 patients in the UK would meet our inclusion criteria and hence would benefit from tocilizumab (ISARIC4C Investigators, personal communication). Sarilumab, an alternative IL-6 antagonist, is available but evidence of its efficacy is inconclusive 15 , 21 , 22 and the results of the largest trial ( NCT04315298 ) are not yet published.…”

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): preliminary results of a randomised, controlled, open-label, platform trial

“…Since complicating bacterial infections are infrequent in the early hospitalisation period of COVID-19, this recognised concern in relation to the use of tocilizumab would be lessened with earlier use. 22 Based upon the ISARIC4C database, approximately 49% of hospitalised COVID-19 patients in the UK would meet our inclusion criteria and hence would benefit from tocilizumab (personal communication, ISARIC4C Investigators). CRP was chosen as the biomarker for inflammation in this study since it is widely used and affordable worldwide, it is correlated with serum IL-6 levels, and early clinical studies of COVID-19 had reported it to be associated with severity and prognosis, with a value of >50 mg/L associated with severe disease and a level of around 75 mg/L distinguishing fatal from non-fatal cases.…”

“…Since complicating bacterial infections are infrequent in the early hospitalisation period of COVID-19, this recognised concern in relation to the use of tocilizumab would be lessened with earlier use. 22…”

Appropriate use of Antimicrobial Therapy For COVID-19 Co-Infection

“…In contrast, a case–control study revealed that patients with cobacterial infection had greater proportion of severe/critical disease at presentation than those without co-infection (80 vs 30%; p < 0.001) [ 5 ]. Most importantly, patients with a co-infection had a prolonged length of hospital stay with an average of 29 ± 6.7 days and carried a higher risk of death than those without co-infection (odds ratio [OR]: 2.84; 95% CI: 1.42–5.66) [ 4 ] as previously reported [ 5 , 6 ].…”