Co-infection with influenza-associated acute respiratory distress syndrome requiring extracorporeal membrane oxygenation

Abstract

The co-infection frequency and impact among influenza-associated acute respiratory distress syndrome (ARDS) patients requiring extracorporeal membrane oxygenation (ECMO) are not known. This retrospective observational analysis concerned data prospectively collected from patients admitted to our medical intensive care unit (ICU) who received ECMO support for influenza-associated ARDS between 2009-2016. Co-infection was defined as occurring within 48 h following ICU admission. Among the 77 ARDS patients requiring ECMO support, 39 (51%) developed co-infections, with Staphylococcus aureus [18 (46%) of the co-infected patients] being the most prevalent pathogen. Panton-Valentin leukocidin (PVL)-producing S. aureus was isolated from 10 patients (56% of S. aureus co-infections and 26% of all co-infections). Co-infected patients were comparable with those without co-infection, except for BMI, initial disease severity and antibiotic treatment prior to admission. Co-infection was associated with higher in-ICU mortality (62% vs. 29%; P = 0.006) and with fewer ECMO-free days [median (IQR) 0 (0-19) vs. 23 (0-46); P = 0.004] and fewer mechanical ventilation-free days [0 (0-0) vs. 6 (0-35); P = 0.003] on Day 60. Multivariable analysis retained age >49 years, pre-ECMO Simplified Acute Physiology Score (SAPS) II score >70 and co-infection as independent predictors of hospital mortality. In conclusion, co-infection is frequent in ECMO-treated patients with influenza-associated ARDS, affecting ca. 50%, and is independently associated with poor outcome. Staphylococcus aureus was the most frequently identified pathogen, with a high rate of PVL-positive S. aureus. Whether specific therapy targeting PVL-producing S. aureus should be given remains to be determined.

Viral infection in community acquired pneumonia patients with fever: a prospective observational study

“…Influenza plays a dominant role in co-infection, which was so severe that needed effective means to decrease death. The Influenza patients diagnosed with severity score CURB 65 and detection method mPCR can be admitted to ICU sooner and start treatment like ECMO and Tamiflu sooner with increased survival (5,6).…”

“…In addition, severe hypoxemic acute respiratory failure and acute respiratory distress syndrome (ARDS) were strongly associated with influenza A (H1N1) in 2009 (3,4). The influenza outbreak was so severe that extracorporeal membrane oxygenation (ECMO) was used to decrease death (5,6).…”

Influenza virus-related critical illness: pathophysiology and epidemiology

“…Current data still lacks proof that the clinical presentation with viral-bacterial co-infections directly leads to worse outcomes, but a growing body of evidence suggests that influenza-bacterial co-infections are associated with higher morbidity and higher mortality [65,[73][74][75][76]. In fact, a recent study showed that the presence of co-infection in adults with influenza-associated acute respiratory syndrome requiring extra-corporeal membrane oxygenation was significantly associated with a fourfold increase in mortality [77], and another study in children with Staphylococcus aureus co-infection with influenza-related critical illness also showed a ninefold significant increase in mortality [78].…”

ECLS-associated infections in adults: what we know and what we don’t yet know

“…Data from several large observational studies suggest, overall, that there is a probable benefit to be derived from the use of ECLS in H1N1-associated severe ARDS refractory to conventional therapy [13][14][15]. Whereas no specific infectious etiology has been identified as a contraindication to the use of ECLS, co-infections in the context of influenzaassociated ARDS, including infections with S. aureus, multidrug-resistant Gram-negative bacteria and Aspergillus, may correlate with lower survival compared with influenza alone [16][17][18][19]. Likewise, concomitant nonpulmonary infections at the time of initiation of ECLS for ARDS may predict worse outcomes and this factor has been incorporated into a validated prognostic scoring system [20].…”