Secondary pneumonia in critically ill ventilated 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 artificial ventilation and are at significant risk of developing a secondary, ventilator-associated pneumonia (VAP). Objectives To study the incidence of VAP, as well as differences in secondary infections, and bacterial lung microbiome composition of ventilated COVID-19 and non-COVID-19 patients. Methods In this prospective observational study, we compared the incidence of VAP and secondary infections using a combination of a TaqMan multi-pathogen array and microbial culture. In addition, we determined the lung microbime composition using 16S RNA analyisis. The study involved eighteen COVID-19 and seven non-COVID-19 patients receiving invasive ventilation in three ICUs located in a single University teaching hospital between April 13th 2020 and May 7th 2020. Results We observed a higher percentage of confirmed VAP in COVID-19 patients. However, there was no statistical difference in the detected organisms or pulmonary microbiome when compared to non-COVID-19 patients. Conclusion COVID-19 makes people more susceptible to developing VAP, partly but not entirely due to the increased duration of ventilation. The pulmonary dysbiosis caused by COVID-19, and the array of secondary infections observed are similar to that seen in critically ill patients ventilated for other reasons.

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 ventilator-days 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.…”

Severe Acute Respiratory Syndrome–Associated Coronavirus 2 Infection and Organ Dysfunction in the ICU: Opportunities for Translational Research

“…Third, significant deposition of microthrombi is common and may partly explain the proposed “L” (low lung weight, low elastance, and low inspiratory driving pressures) and “H” (high lung weight, high elastance, and high inspiratory driving pressures) ARDS phenotypes ( 81 ), although some experts have refuted the presence of the L phenotype. Fourth, COVID-19 patients are reported to have increased susceptibility to ventilator-associated pneumonia, for as yet undefined reasons compared with non–COVID-19 patients receiving invasive ventilation ( 82 ). Respiratory effects also occur along with MOF, profound alterations in coagulation, and hyperinflammatory cytokine profiles that are observed in other critical illnesses.…”

Influenza- and COVID-19-associated pulmonary aspergillosis: are the pictures different?

“…The background of patients suffering from Coronavirus Disease 2019 (COVID-19) also appears to be highly compatible with the occurrence of IPA (9). ICU patients admitted for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and in uenza virus infections share speci c features, commonly described to increase the risk for ventilator associated pneumonia (10) and particularly fungal diseases including ARDS, possible corticosteroid administration, and systemic dysregulation of immune function (11). The incidence of COVID-19-associated pulmonary aspergillosis (CAPA) in ICU patients varies according to the major national cohorts from the United Kingdom (14.1%), Italy (27.7%), Germany (26.3%), the Netherlands (19.4%), and France (National MY-CO-VID clinical trial: 21.8%) (12)(13)(14)(15)(16) and are similar to the rate of IAPA observed in ICU cohorts (19%) from Belgium and the Netherlands (8).…”