Increased susceptibility to intensive care unit-acquired pneumonia in severe COVID-19 patients: a multicentre retrospective cohort study

Abstract

Background The aim of this study is to determine whether severe COVID-19 patients harbour a higher risk of ICU-acquired pneumonia. Methods This retrospective multicentre cohort study comprised all consecutive patients admitted to seven ICUs for severe COVID-19 pneumonia during the first COVID-19 surge in France. Inclusion criteria were laboratory-confirmed SARS-CoV-2 infection and requirement for invasive mechanical ventilation for 48 h or more. Control groups were two historical cohorts of mechanically ventilated patients admitted to the ICU for bacterial or non-SARS-CoV-2 viral pneumonia. The outcome of interest was the development of ICU-acquired pneumonia. The determinants of ICU-acquired pneumonia were investigated in a multivariate competing risk analysis. Result One hundred and seventy-six patients with severe SARS-CoV-2 pneumonia admitted to the ICU between March 1st and 30th June of 2020 were included into the study. Historical control groups comprised 435 patients with bacterial pneumonia and 48 ones with viral pneumonia. ICU-acquired pneumonia occurred in 52% of COVID-19 patients, whereas in 26% and 23% of patients with bacterial or viral pneumonia, respectively (p < 0.001). Times from initiation of mechanical ventilation to ICU-acquired pneumonia were similar across the three groups. In multivariate analysis, the risk of ICU-acquired pneumonia remained independently associated with underlying COVID-19 (SHR = 2.18; 95 CI 1.2–3.98, p = 0.011). Conclusion COVID-19 appears an independent risk factor of ICU-acquired pneumonia in mechanically ventilated patients with pneumonia. Whether this is driven by immunomodulatory properties by the SARS-CoV-2 or this is related to particular processes of care remains to be investigated.

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

“…We conducted a sensitivity analysis only considering the studies reporting data on the occurrence of VAP in patients with COVID-19 and comparison groups of patients admitted to ICU without COVID-19 (Table 1). 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].…”

“…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.…”

“…The patients evaluated in the included studies had a mean or median age ranging from 49 to 69.5 years, with a percentage of female gender ranging from 18% to 55%. All the studies were single-arm studies, except five also including patients admitted to ICU without COVID-19 as a comparison group [17,19,21,22,28]. The median duration of mechanical ventilation prior to VAP in the included patients ranged from 7 to 13 days.…”

“…The pooled estimate of the occurrence of VAP was 42.5% (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].…”