Multi-Drug Resistance Bacterial Infections in Critically Ill Patients Admitted with COVID-19

Abstract

Introduction. It is known that bacterial infections represent a common complication during viral respiratory tract infections such as influenza, with a concomitant increase in morbidity and mortality. Nevertheless, the prevalence of bacterial co-infections and secondary infections in critically ill patients affected by coronavirus disease 2019 (COVID-19) is not well understood yet. We performed a review of the literature currently available to examine the incidence of bacterial secondary infections acquired during hospital stay and the risk factors associated with multidrug resistance. Most of the studies, mainly retrospective and single-centered, highlighted that the incidence of co-infections is low, affecting about 3.5% of hospitalized patients, while the majority are hospital acquired infections, developed later, generally 10–15 days after ICU admission. The prolonged ICU hospitalization and the extensive use of broad-spectrum antimicrobial drugs during the COVID-19 outbreak might have contributed to the selection of pathogens with different profiles of resistance. Consequently, the reported incidence of MDR bacterial infections in critically ill COVID-19 patients is high, ranging between 32% to 50%. MDR infections are linked to a higher length of stay in ICU but not to a higher risk of death. The only risk factor independently associated with MDR secondary infections reported was invasive mechanical ventilation (OR 1.062; 95% CI 1.012–1.114), but also steroid therapy and prolonged length of ICU stay may play a pivotal role. The empiric antimicrobial therapy for a ventilated patient with suspected or proven bacterial co-infection at ICU admission should be prescribed judiciously and managed according to a stewardship program in order to interrupt or adjust it on the basis of culture results.

Distribution of Pathogens and Predictive Values of Biomarkers of Inflammatory Response at ICU Admission on Outcomes of Critically Ill COVID-19 Patients with Bacterial Superinfections—Observations from National COVID-19 Hospital in Croatia

“…The percentage of patients with Acinetobacter baumanii superinfections in our cohort was significantly higher compared to the results of a review by Pasero et al [ 16 ], where it varied between 0.8–61%, with most studies reporting results between 30 and 40%. The most probable reason for the reported prevalence of Acinetobacter baumanii is the fact that compared to other centers where ICU beds were located in ICUs, in UH Dubrava there was an increased number of ICU beds (85 beds in total, of which around one third were located in rooms that were repurposed to become makeshift ICUs) and reduced nurse/patient ratio, which would need to be 1:1 in mechanically ventilated patients but was 1:2.5–1:3 [ 31 , 32 ].…”

“…Airway dysfunction, cytopathology and tissue destruction induced by SARS-CoV-2 infection or during bacterial co-infection may facilitate systemic dissemination of the virus and/or bacterial co-pathogens, dramatically increasing the risk of blood infections and sepsis [ 12 , 13 ]. In addition, due to the widely accepted therapeutic regimen of corticosteroid therapy, which reduces COVID-19 mortality [ 14 ] but may promote immunosuppressive states, [ 15 , 16 ] combined with irrational use of antibiotics (in hospital but unfortunately also before hospital admission) [ 17 ], certain ICU stay (non-COVID-19) factors should be also taken into account as contributing factors leading to increased incidence of superinfections: presence of intravascular [ 18 ] and urinary [ 19 ] catheters. Multidrug-resistant pathogen infections are of special concern in these patients due to their deleterious effect on ICU and hospital stays and mortality [ 16 , 20 ].…”

Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution

“…Differently, no significant changes were found in carbapenemase-producing Enterobacteriaceae colonization and infection during the two study periods. Concerning the topic of multi-drug resistant (MDR) bacteria secondary infection, Pasero and collaborators performed a review of the literature to investigate the incidence of this important co-infections/superinfections [ 72 ]. According to the authors, most of the studies (mainly retrospective and single-centred) reported low rates of co-infections but a significant incidence of hospital-acquired infections developing about 10–15 days after ICU admission.…”

Upregulating Human Cathelicidin Antimicrobial Peptide LL-37 Expression May Prevent Severe COVID-19 Inflammatory Responses and Reduce Microthrombosis

“…LL-37 also kills Candida albicans , most effectively as a cleavage fragment RK-31 ( 30 ). Covid patients in the ICU for more than a few days commonly suffer from co-infections, and often with resistant species of bacteria and fungi, worsening prognosis ( 31 – 33 ).…”