Epidemiology and microbiology of ventilator-associated pneumonia in COVID-19 patients: a multicenter retrospective study in 188 patients in an un-inundated French region

Abstract

Background The COVID-19 pandemic is responsible for many hospitalizations in intensive care units (ICU), with widespread use of invasive mechanical ventilation (IMV) which exposes patients to the risk of ventilator-associated pneumonia (VAP). The characteristics of VAP in COVID-19 patients remain unclear. Methods We retrospectively collected data on all patients hospitalized for COVID-19 during the first phase of the epidemic in one of the seven ICUs of the Pays-de-Loire region (North-West France) and who were on invasive mechanical ventilation for more than 48 h. We studied the characteristics of VAP in these patients. VAP was diagnosed based on official recommendations, and we included only cases of VAP that were confirmed by a quantitative microbiological culture. Findings We analyzed data from 188 patients. Of these patients, 48.9% had VAP and 19.7% experienced multiple episodes. Our study showed an incidence of 39.0 VAP per 1000 days of IMV (until the first VAP episode) and an incidence of 33.7 VAP per 1000 days of IMV (including all 141 episodes of VAP). Multi-microbial VAP accounted for 39.0% of all VAP, and 205 pathogens were identified. Enterobacteria accounted for 49.8% of all the isolated pathogens. Bacteremia was associated in 15 (10.6%) cases of VAP. Pneumonia was complicated by thoracic empyema in five cases (3.5%) and by pulmonary abscess in two cases (1.4%). Males were associated with a higher risk of VAP (sHR 2.24 CI95% [1.18; 4.26] p = 0.013). Interpretation Our study showed an unusually high incidence of VAP in patients admitted to the ICU for severe COVID-19, even though our services were not inundated during the first wave of the epidemic. We also noted a significant proportion of enterobacteria. VAP-associated complications (abscess, empyema) were not exceptional. Registration As an observational study, this study has not been registered.

Ventilator-Associated Pneumonia in Patients with COVID-19: A Systematic Review and Meta-Analysis

“…Cumulative estimates of occurrence of VAP sorted by the sample size of the included studies are provided as Figure S1 in Supplementary Material S2. Eleven of the included studies reported data on mortality in patients with COVID-19 and VAP [9,15,16,20,21,[23][24][25][30][31][32]. The pooled estimated occurrence of mortality (at the longest available follow-up) was 42.7% (95% C.I.…”

“…The full search output is available as Supplementary Material S3. After the exclusion of duplicates and not relevant records, twenty studies were included in the systematic review and metaanalysis, for a total of 2611 patients with COVID-19 who developed at least one episode of VAP [9,[15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. The process of inclusion and exclusion is detailed in the PRISMA flow diagram, provided in Figure 1.…”

“…The characteristics of the included studies are provided in Table 1. Eighteen studies had an observational retrospective design (18/20, 90%), of which five were multicenter [9,17,22,27,32] and thirteen were performed in a single center [15,16,[19][20][21][24][25][26][28][29][30][31][32][33]. Two studies had a prospective observational design (2/20, 10%) and were multicenter.…”

“…In this analysis, conducted on the unadjusted data provided by five studies with comparison groups [17,19,21,22,28], we observed a significantly higher risk of VAP in patients with COVID-19, compared to patients without ; P = 0.015; I 2 = 67.7%; Figure 4). We also performed a sensitivity analysis including studies reporting data on mortality in patients with COVID-19 and VAP in comparison to the same patients' cohort who did not develop VAP [15,16,20,21,23,25,30,31]. This unadjusted analysis found no significantly different risk of death in COVID-19 patients with VAP versus non VAP (OR 1.16; 95% C.I.…”

“…32.8-52.7%; 2150/4546 patients; I 2 = 97%; Figure S5, Supplementary Material S2) when considering only multicenter studies [9,17,18,22,23,27], and 46.1% (95% C.I. 30.8-62.1%; 461/1047 patients; I 2 = 95%; Figure S6, Supplementary Material S2) when considering only single center studies [15,16,[19][20][21][24][25][26][28][29][30][31].…”