Nosocomial Infections in COVID-19 Patients Treated with Immunomodulators: A Narrative Review

Abstract

Nosocomial infections pose an imminent challenge to hospitalized Coronavirus disease-19 (COVID-19) patients due to complex interplay of dysregulated immune response combined with immunomodulator therapy. In the pre-pandemic era, immunomodulatory therapy has shown benefit in certain autoimmune conditions with untamed inflammatory response. Efforts to recapitulate these immunomodulatory effects in COVID-19 patients has gained impetus and were followed by NIH COVID-19 expert panel recommendations. The current NIH guideline recommends interleukin-6 inhibitors (tocilizumab and sarilumab) and Janus kinase inhibitors (baricitinib and tofacitinib). Several landmark research trials like COVAVTA, EMPACTA, REMDACTA, STOP-COVID and COV BARRIER have detailed the various effects associated with administration of immunomodulators. The historical evidence of increased infection among patients receiving immunomodulators for autoimmune conditions, raised concerns regarding administration of immunomodulators in COVID-19 patients. The aim of this review article is to provide a comprehensive update on the currently available literature surrounding this issue. We reviewed 40 studies out of which 37 investigated IL-6 inhibitors and 3 investigated JAK inhibitors. Among the studies reviewed, the reported rates of nosocomial infections among the COVID-19 patients treated with immunomodulators were similar to patients receiving standard of care for COVID-19. However, these studies were not powered to assess the side effect profile of these medications. Immunomodulators, by dampening the pyrogenic response and inflammatory markers may delay detection of infections among the patients. This underscores the importance of long-term surveillance which are necessary to discover the potential risks associated with these agents.

The Pattern and Impact of Hospital-Acquired Infections and Its Outlook in India

“…Ramasamy et al [25] 2022 Rate of nosocomial infection is similar in patients treated with immunomodulators or with standard care protocol in COVID-19 patients.…”

“…COVID-19 showed a balanced effect on HAI, the positive sides being the use of personal protective equipment, hand hygiene, and distancing. The negative impact was seen due to the overuse of antibiotics [ 24 , 25 ]. Methicillin-resistant Staphylococcus aureus (MRSA) has remained a burden organism to deal with during the pandemic.…”

“…The longer duration of hospital stay associated with severe COVID-19 infection was responsible for causing superadded bacterial coinfections particularly in those requiring prolonged mechanical ventilation and those admitted in ICU [ 24 ]. COVID-19 was associated with increased use of immunomodulators and steroids which reduces pulmonary inflammation but predisposes the patient to further infections [ 25 ]. The specified authorities in a hospital form the chief base in its control.…”