Ventilator-associated pneumonia in critically ill patients with COVID-19

Abstract

Background Pandemic COVID-19 caused by the coronavirus SARS-CoV-2 has a high incidence of patients with severe acute respiratory syndrome (SARS). Many of these patients require admission to an intensive care unit (ICU) for invasive ventilation and are at significant risk of developing a secondary, ventilator-associated pneumonia (VAP). Objectives To study the incidence of VAP and bacterial lung microbiome composition of ventilated COVID-19 and non-COVID-19 patients. Methods In this retrospective observational study, we compared the incidence of VAP and secondary infections using a combination of microbial culture and a TaqMan multi-pathogen array. In addition, we determined the lung microbiome composition using 16S RNA analysis in a subset of samples. The study involved 81 COVID-19 and 144 non-COVID-19 patients receiving invasive ventilation in a single University teaching hospital between March 15th 2020 and August 30th 2020. Results COVID-19 patients were significantly more likely to develop VAP than patients without COVID (Cox proportional hazard ratio 2.01 95% CI 1.14–3.54, p = 0.0015) with an incidence density of 28/1000 ventilator days versus 13/1000 for patients without COVID (p = 0.009). Although the distribution of organisms causing VAP was similar between the two groups, and the pulmonary microbiome was similar, we identified 3 cases of invasive aspergillosis amongst the patients with COVID-19 but none in the non-COVID-19 cohort. Herpesvirade activation was also numerically more frequent amongst patients with COVID-19. Conclusion COVID-19 is associated with an increased risk of VAP, which is not fully explained by the prolonged duration of ventilation. The pulmonary dysbiosis caused by COVID-19, and the causative organisms of secondary pneumonia observed are similar to that seen in critically ill patients ventilated for other reasons.

Respiratory bacterial co-infections in intensive care unit-hospitalized COVID-19 patients: Conventional culture vs BioFire FilmArray pneumonia Plus panel

“…In line with previous works, we found that respiratory bacterial co-infections are quite common in critically ill COVID-19 patients (more than 30% of positive cultures), with Pseudomonas aeruginosa (14.7%), Klebsiella pneumoniae (6.9%) and Staphylococcus aureus (6.5%) the most detected pathogens ( Caméléna et al, 2021 ; Maes et al, 2021 ; Hughes et al, 2020 ).…”

Incidence and Prognosis of Ventilator-Associated Pneumonia in Critically Ill Patients with COVID-19: A Multicenter Study

“…Therefore, since some patients may have experienced more than one VAP episode, we also cannot exclude an underestimation of the true incidence rate of VAP in critically ill COVID-19 patients. With regard to organisms isolated from deep respiratory specimens in patients with VAP in our series, the higher frequency of Gram-negative bacteria we registered is in line with recent data from other countries [22,26,27].…”

“…There are different reasons that may explain this high incidence rate we registered. On the one hand, a truly increased risk of VAP in COVID-19 patients (which is in line with the high incidence rate of 28 episodes per 1000 ventilatordays registered in a recent UK study and with the high reported prevalence of 58% in a large cohort of 4244 critically ill patients with COVID-19 [22,23]), might be explained by different reasons: (i) a potential increased predisposition to bacterial superinfection, on the top of lung damage caused by COVID-19; (ii) the virus-related immunosuppressive effect with deep lymphopenia; (iii) the potential concomitant anti-inflammatory or immunosuppressive effect of steroids and biologic agents (e.g., anti-IL-6 receptor monoclonal antibodies) [24,25]. On the other hand, supporting instead a possible artefactual increase of the registered VAP incidence rate, we may have included some patients diagnosed with VAP who in reality did not have VAP, since we used a broad definition of VAP that is generally used for enrollment in clinical trials rather than for epidemiological purposes.…”

Staphylococcus aureus ventilator-associated pneumonia in patients with COVID-19: clinical features and potential inference with lung dysbiosis

“…Very recently, the OUTCOMEREA network describing clinical and epidemiological features of COVID-19 patients observed that these patients were significantly more likely to develop late-onset (> 7 days) ICU-acquired bloodstream infections compared to non-COVID-19 patients [ 42 ]. Furthermore, COVID-19 patients were found to develop more VAP than patients without COVID-19 despite sharing a similar pulmonary microbiota [ 43 ]. Until recently (i.e., in pre–COVID-19 era), bacteremic SA pneumonia was considered as relatively uncommon despite being associated with high mortality rates [ 39 ].…”