Hospital-Acquired Infections in Critically Ill Patients With COVID-19

Abstract

Background Few small studies have described hospital-acquired infections (HAIs) during COVID-19. Research Question What patient characteristics in critically ill patients with COVID-19 are associated with HAIs and how do HAIs associate with outcomes in these patients? Study Design and Methods Multicenter retrospective analysis of prospectively collected data including adult patients with severe COVID-19, admitted to 8 Italian hub hospitals from February 20, 2020, to May 20, 2020. Descriptive statistics, univariable and multivariable Weibull regression models were used to assess incidence, microbial etiology, resistance patterns, risk factors (i.e., demographics, comorbidities, exposure to medication), and impact on outcomes (i.e., ICU survival, length of ICU and hospital stay and duration of mechanical ventilation) of microbiologically-confirmed HAIs. Results Of the 774 included patients, 359 (46%) patients developed 759 HAIs (44.7 infections/1000 ICU patient-days, 35% multi-drug resistant (MDR) bacteria). Ventilator-associated pneumonia (VAP) (389, 50%), bloodstream infections (183, 34%), and catheter related blood stream infections (74, 10%) were the most frequent HAIs, with 26.0 (23.6-28.8) VAPs/1000 patient intubation-days, 11.7(10.1-13.5) BSIs/1000 ICU patient-days, and 4.7 (3.8-5.9) CRBSIs/1000 patient-days. Gram-negative bacteria (especially Enterobacterales ) and Staphylococcus aureus caused 64% and 28% of VAPs. Variables independently associated with infection were age, PEEP and treatment with broad-spectrum antibiotic at admission. 234 patients (30%) died in ICU (15.3 deaths/1000 ICU patient-days). Patients with HAIs complicated by septic shock had almost doubled mortality (52% vs. 29%), while non-complicated infections did not affect mortality. HAIs prolonged mechanical ventilation (24(14-39) vs. 9(5-13) days; p<0.001), ICU and hospital stay (24(16-41) vs. 9(6-14) days, p=0.003; and (42(25-59) vs. 23(13-34) days, p<0.001). Interpretation Critically-ill COVID-19 patients are at high risk for HAIs, especially VAPs and BSIs due to MDR organisms. HAIs prolong mechanical ventilation and hospitalization, and HAIs complicated by septic-shock almost doubled mortality.

Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study

“…Additionally, an association of two antibiotics could be argued. This is the first study toreport such an association, to our best knowledge, and its results need to be confirmed in further studies.Finally, the association of VAP with positive blood cultures is not a veritable surprise, considering the high frequency of bloodstream infections in COVID-19 patients hospitalised in ICU [ 34 ].…”

Gut microbiome dysbiosis during COVID-19 is associated with increased risk for bacteremia and microbial translocation.

“…Differences in gut bacterial populations relative to healthy controls were observed in all COVID-19 patients, but most strongly in patients who were treated with antibiotics during their hospitalization 4 . Most recently, COVID-19 patients treated with broad spectrum antibiotics at admission were shown to have increased susceptibility to multi-drug resistant infections and nearly double the mortality rate from septic shock 5,6 , and a recent meta-analysis found that over 14% of 3,338 COVID-19 patients acquired a secondary bacterial infection 7 . However, the causal direction of the relationship between disease symptoms and gut bacterial populations is not yet clear.…”

“…Consequently, enterococcal dominations have been associated with 9-fold increased risk of bloodstream infections (BSIs) with vancomycin-resistant Enterococcus (VRE), and domination by Gram-negative proteobacteria with 5-fold increased risk of Gram-negative rod BSIs 13 . Bacterial co-infection can also cause life-threatening complications in patients with severe viral infections 6,17 ; therefore, antibacterial agents were administered empirically to nearly all critically ill suspected COVID-19 patients since the incidence of bacterial superinfection was unknown early during the pandemic 4,18 . However, it is now known that nosocomial infection during prolonged hospitalization is the primary threat to patients with COVID-19 19 , rather than bacterial co-infection upon hospital admission 7,[20][21][22] .…”

Rationale for Polyclonal Intravenous Immunoglobulin Adjunctive Therapy in Covid19 Patients: Report of a Structured Multidisciplinary Consensus

“…Patients with immune paralysis are unable to mount an appropriate inflammatory response and become prone to viral reactivation and secondary or breakthrough infections mostly by opportunistic agents. A high rate of secondary bacterial and viral infections have been reported by numerous studies in COVID19 patients, especially in those requiring mechanical ventilation and ICU admission [53,54].…”

“…In addition, as for other categories of complicated ICU patients, infections from multidrug-resistant bacteria or Aspergillus spp. are frequent in COVID19 patients [53,[60][61][62]. Therefore, sepsis and septic shock often complicate the ICU stay and are a major cause of mortality [63][64][65].…”