Recognition and management of respiratory co-infection and secondary bacterial pneumonia in patients with COVID-19

Wu, Chao; Adhi, Fatima; Highland, Kristin B.

doi:10.3949/ccjm.87a.ccc015

Cited by 69 publications

(76 citation statements)

References 42 publications

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“…Bacterial pneumonia is also hypothesized to occur as a complication of COVID-19, though reports are inconsistent. 30,31,32 While we observed bacterial pneumonia (3•6%) on admission, these results should be interpreted with caution as it may be underreported in patients who are already diagnosed with COVID-19. Furthermore, much of the bacterial pneumonia in this population may be associated with invasive ventilation, and thus develops over the course of inpatient stay rather than on admission.…”

Section: Discussionmentioning

confidence: 52%

Descriptive epidemiology of 16,780 hospitalized COVID-19 patients in the United States

Chawla¹,

Rizzo²,

Zalocusky³

et al. 2020

Preprint

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BACKGROUND: Despite the significant morbidity and mortality caused by the 2019 novel coronavirus disease (COVID-19), our understanding of basic disease epidemiology remains limited. This study aimed to describe key patient characteristics, comorbidities, treatments, and outcomes of a large U.S.-based cohort of patients hospitalized with COVD-19 using electronic health records (EHR). METHODS: We identified patients in the Optum De-identified COVID-19 EHR database who had laboratory-confirmed COVID-19 or a presumptive diagnosis between 20 February 2020 and 6 June 2020. We included hospitalizations that occurred 7 days prior to, or within 21 days after, COVID-19 diagnosis. Among hospitalized patients we describe the following: vital statistics and laboratory results on admission, relevant comorbidities (using diagnostic, procedural, and revenue codes), medications (NDC, HCPC codes), ventilation, intensive care unit (ICU) stay, length of stay (LOS), and mortality. RESULTS: We identified 76,819 patients diagnosed with COVID-19, 16,780 of whom met inclusion criteria for COVID-related hospitalization. Over half the cohort was over age 50 (74.5%), overweight or obese (77.2%), or had hypertension (58.1%). At admission, 30.3% of patients presented with fever (>38C) and 32.3% had low oxygen saturation (<90%). Among the 16,099 patients with complete hospital records, we observed that 58.9% had hypoxia, 23.4% had an ICU stay during hospitalization, 18.1% were ventilated, and 16.2% died. The median LOS was 6 days (IQR: 4, 11). CONCLUSIONS: To our knowledge, this is the largest descriptive study of patients hospitalized with COVID-19 in the United States. We report summary statistics of key clinical outcomes that provide insights to better understand COVID-19 disease epidemiology.

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Section: Discussionmentioning

confidence: 52%

Descriptive epidemiology of 16,780 hospitalized COVID-19 patients in the United States

Chawla¹,

Rizzo²,

Zalocusky³

et al. 2020

Preprint

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“…Testing was not done for Mycoplasma pneumoniae which was a common superinfecting pathogen in one review [26]. Also, the three Aspergillus isolates did not represent invasive disease which was a concern of several prior published reviews [26,27]. Our study does suggest that following admission and intubation, COVID-19 pneumonia patients have the same predisposition to colonization and infections due to nosocomial pathogens wellknown in hospital-acquired and ventilator-associated pneumonias.…”

Section: Discussionmentioning

confidence: 69%

Bacterial and Fungal Growth in Sputum Cultures from 165 COVID-19 Pneumonia Patients Requiring Intubation: Evidence for Antimicrobial Resistance Development and Analysis of Risk Factors

Liu

Yaron

Piraino

et al. 2020

Preprint

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Background: Coronavirus SARS-CoV-2 causes COVID-19 illness which can progress to severe pneumonia. Empiric antibacterials are often employed though frequency of bacterial superinfection is debated and concerns raised about selection of bacterial antimicrobial resistance. We evaluated sputum bacterial and fungal growth from 165 intubated COVID-19 pneumonia patients. Objectives were to determine frequency of culture positivity, risk factors for and outcomes of positive cultures, and timing of antimicrobial resistance development. Methods: Retrospective reviews were conducted of COVID-19 pneumonia patients requiring intubation admitted to a 1,058-bed four community hospital system on the east coast United States, March 1 to May 1, 2020. Length of stay (LOS) was expressed as mean (standard deviation); 95% confidence interval (95% CI) was computed for overall mortality rate using the exact binomial method, and overall mortality was compared across each level of a potential risk factor using a Chi-Square Test of Independence. All tests were two-sided, and significance level was set to 0.05.Results: Average patient age was 68.7 years. Eighty-three patients (50.3% of total) originated from home, 10 from group homes (6.1% of total), and 72 from nursing facilities (43.6% of total). Mortality was 62.4%, highest for nursing home residents (80.6%). Findings from 253 sputum cultures overall were evaluated and did not suggest acute bacterial or fungal infection in 89 (54%) of 165 individuals sampled within 24 hours of intubation. Cultures > one week following intubation did grow potential pathogens in 72 (64.9%) of 111 cases with 70.8% consistent with late pneumonia and 29.2% suggesting colonization. Twelve (10.8% of total) of these late post-intubation cultures revealed worsened antimicrobial resistance predominantly in Pseudomonas, Enterobacter, or Staphylococcus aureus.Conclusions: In severe COVID-19 pneumonia, a radiographic ground glass interstitial pattern and lack of purulent sputum suggest antibacterials are not needed. Discontinuation of empiric antibacterials should be considered after 48 hours in absence of sputum to culture or results reported "without growth" or "normal flora." Continuing longterm hospitalisation and antibiotics are associated with sputum cultures reflective of hospital-acquired microbes and increasing antimicrobial resistance.Trial registration: Not applicable as this was a retrospective chart review study without interventional arm.

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“…In patients with concomitant viral infections, specifically in COVID-19 patients, deterioration of the respiratory status of the patient can be a sign of the progression of the COVID-19 or secondary bacterial infection. Additional findings that increase the likelihood of bacterial infection and indicate empiric antibiotic therapy prior to getting culture results include new leukocytosis, particularly neutrophilic leukocytosis, new fever, and worsening respiratory failure [4].…”

Section: Discussionmentioning

confidence: 99%

Unfortunate Outcomes in Patients With SARS-CoV-2 Superimposed on Pneumococcal Pneumonia

Elkattawy

Alyacoub

Mowafy³

et al. 2020

Cureus

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The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes, coronavirus disease 2019 (COVID-19), continue to have socioeconomic as well as health implications worldwide. The virus has already led to over 200,000 deaths in the United States alone. This is most likely secondary to quick respiratory deterioration seen in patients inflicted with the virus. In other words, the heightened inflammatory response leads to major organ system damage, which leads to rapid decompensation of the patient's clinical condition. Interestingly enough, some patients present with both the novel virus as well as a superimposed bacterial infection that further complicates the management of the disease. We present a case of a patient with a positive polymerase chain reaction (PCR) test for SARS-CoV-2 as well as a pneumococcal urine antigen; he was treated with both appropriate antibiotics as well as dexamethasone and remdesivir for pneumonia and novel virus, respectively. The patient's hypoxemia continued to worsen with appropriate means of oxygenation and eventually led to cardiac arrest.

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Recognition and management of respiratory co-infection and secondary bacterial pneumonia in patients with COVID-19

Cited by 69 publications

References 42 publications

Descriptive epidemiology of 16,780 hospitalized COVID-19 patients in the United States

Descriptive epidemiology of 16,780 hospitalized COVID-19 patients in the United States

Bacterial and Fungal Growth in Sputum Cultures from 165 COVID-19 Pneumonia Patients Requiring Intubation: Evidence for Antimicrobial Resistance Development and Analysis of Risk Factors

Unfortunate Outcomes in Patients With SARS-CoV-2 Superimposed on Pneumococcal Pneumonia

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