ICU-Acquired Colonization and Infection Related to Multidrug-Resistant Bacteria in COVID-19 Patients: A Narrative Review

Abstract

A large proportion of ICU-acquired infections are related to multidrug-resistant bacteria (MDR). Infections caused by these bacteria are associated with increased mortality, and prolonged duration of mechanical ventilation and ICU stay. The aim of this narrative review is to report on the association between COVID-19 and ICU-acquired colonization or infection related to MDR bacteria. Although a huge amount of literature is available on COVID-19 and MDR bacteria, only a few clinical trials have properly evaluated the association between them using a non-COVID-19 control group and accurate design and statistical methods. The results of these studies suggest that COVID-19 patients are at a similar risk of ICU-acquired MDR colonization compared to non-COVID-19 controls. However, a higher risk of ICU-acquired infection related to MDR bacteria has been reported in several studies, mainly ventilator-associated pneumonia and bloodstream infection. Several potential explanations could be provided for the high incidence of ICU-acquired infections related to MDR. Immunomodulatory treatments, such as corticosteroids, JAK2 inhibitors, and IL-6 receptor antagonist, might play a role in the pathogenesis of these infections. Additionally, a longer stay in the ICU was reported in COVID-19 patients, resulting in higher exposure to well-known risk factors for ICU-acquired MDR infections, such as invasive procedures and antimicrobial treatment. Another possible explanation is the surge during successive COVID-19 waves, with excessive workload and low compliance with preventive measures. Further studies should evaluate the evolution of the incidence of ICU-acquired infections related to MDR bacteria, given the change in COVID-19 patient profiles. A better understanding of the immune status of critically ill COVID-19 patients is required to move to personalized treatment and reduce the risk of ICU-acquired infections. The role of specific preventive measures, such as targeted immunomodulation, should be investigated.

Pseudomonas aeruginosa Infections in Patients with Severe COVID-19 in Intensive Care Units: A Retrospective Study

“…In their narrative review, Gaudet et al reported that critically ill COVID-19 patients presented with a greater incidence of HAIs with MDR isolates in the ICU. These authors highlighted several pathophysiological factors that could explain these findings, including COVID-19-mediated post-aggressive immunoparalysis; exposure to antibiotics, steroids, and other immunomodulating agents; a longer ICU stay; exposure to invasive devices; and organizational constraints triggered by the pandemic [29]. During the first waves of the COVID-19 pandemic, nurses in the ICU had an excessive workload; this increase in workload was associated with poor quality of care, unfavourable patient safety, and unfavourable infection prevention [30].…”

“…All patients (100%) received oxygenation support during their ICU stay: 22% were treated by extracorporeal membrane oxygenation, and 94% were treated with invasive mechanical ventilation for a median length of 30 days (Q1-Q3: [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]. The use of prone positioning, corticosteroids, and neuromuscular blockers was prescribed for most patients (86%, 69%, and 61%, respectively).…”

Incidence of Carbapenem‐Resistant Gram‐Negative Bacterial Infections in Critically Ill Patients with COVID‐19 as Compared to Non‐COVID‐19 Patients: A Prospective Case‐Control Study

“…In a recent review of published studies on the impact of COVID-19 infection in the incidence of ICU-acquired MDR colonization/infection, the authors concluded that MDR bacterial superinfection or colonization is similar or potentially lower in COVID-19 patients vs. controls [ 16 ]. Therefore, according to our results, the higher mortality rate observed in critically ill COVID-19 patients was associated with higher disease severity, as assessed with the SOFA score, and the higher presence of comorbidities in this population and not with CRGN bacterial infections.…”

“…are common Gram-negative resistant pathogens that account for bacterial superinfections in COVID-19 patients [ 9 , 11 , 14 , 15 ]. However, most previous studies estimating the risk of MDR infections in COVID-19 patients did not include a comparative non-COVID-19 group of patients to counterbalance the contribution of the ICU epidemiology, which is especially necessary in ICUs with a high prevalence of MDR isolates [ 16 ].…”