Ventilator Acquired Pneumonia in COVID-19 ICU Patients: A Retrospective Cohort Study during Pandemia in France

Abstract

Describe the characteristics of ventilation-acquired pneumonia (VAP) and potential risk factors in critically ill Sars-Cov-2 patients admitted in three French public hospitals during the first year of the COVID-19 pandemic. We conducted a monocentric retrospective study in seven Marseille intensive care units (ICUs) aiming to describe VAP characteristics and identify their risk factors. VAP patients were compared to a non-VAP control group. From March to November 2020, 161 patients admitted for viral-induced acute respiratory failure (ARF) requiring invasive mechanical ventilation (IMV) were included. This cohort was categorized in two groups according to the development or not of a VAP during their stay in ICU. 82 patients (51%) developed ventilation-acquired pneumonia. Most of them were men (77%) and 55% had hypertension. In the VAP population, 31 out of 82 patients (38%) had received dexamethasone and 47% were administered antibiotic course prior to ICU admission. An amount of 88% of respiratory infections were late VAPs with a median delay of 10 days from the onset of IMV. Gram negative bacteria were responsible for 62% of VAPs with Pseudomonas spp. being the most documented bacteria. Less than a third of the ICU-acquired infections were due to multidrug resistant (MDR) bacteria mainly displaying AmpC cephalosporin hyper production resistance phenotype. Multivariate analysis revealed that early Dexamethasone administration in ICU, male sex, older age and ROX score were risk factors for VAP whereas pre-ICU antimicrobial treatment and higher IGS 2 were protective factors. VAP is a frequent ICU-related complication affecting half of patients infected with Sars-Cov-2 and requiring IMV. It was responsible for increased morbidity due to a longer ICU and hospital stay. VAP risk factors included demographic factors such as age and sex. Dexamethasone was associated with a threefold greater risk of developing VAP during ICU stay. These results need to be comforted by large multi-centric studies before questioning the only available and effective treatment against Sars-Cov-2 in ICU patients.

Incidence, microbiological and immunological characteristics of ventilator-associated pneumonia assessed by bronchoalveolar lavage and endotracheal aspirate in a prospective cohort of COVID-19 patients: CoV-AP study

“…VAP aetiology in our cohort was in line with studies conducted by our group and others during the first COVID-19 pandemic wave [ 18 , 26 , 28 ]. However, we found MDROs in less than 3% of VAP with conventional culture and 7.3% with molecular microbiology, much lower than what was reported in previous studies by Grasselli et al in Italy and Moreno et al in France at 35% and 28% respectively [ 18 , 28 ]. Implementing antimicrobial stewardship (AMS) and preventive strategies both prior to and during the ICU stay has likely contributed to sharply reduce the burden of MDROs across different pandemic waves [ 14 , 29 ].…”

After SARS-CoV-2 Pandemics: New Insights into ICU-Acquired Pneumonia

“…In fact, VAP is the most important nosocomial infection we have faced during the pandemics. In a retrospective analysis of mechanically ventilated SARS-CoV-2 ARF in France, Moreno et al reported an incidence of more than 50% [ 8 ], which is consistent with the findings of the French multicenter OUTCOME-REA group and a systematic literature review [ 9 ]. All studies reported a high risk of VAP, mainly occurring late during mechanical ventilation, due to Staphylococcus aureus, non-fermentative Gram-negative bacteria, and multidrug-resistant Enterobacterales.…”

“…All studies reported a high risk of VAP, mainly occurring late during mechanical ventilation, due to Staphylococcus aureus, non-fermentative Gram-negative bacteria, and multidrug-resistant Enterobacterales. VAP occurred in the most severe patients, who were more likely to receive corticosteroids, and is associated with low viral clearance [ 8 , 9 , 10 ].…”

Risk factors for ventilator‐associated lower respiratory tract infection in COVID‐19, a retrospective multicenter cohort study in Sweden

“…Our results could support that for patients with severe COVID‐19 requiring at least 48 h of IMV, corticosteroids may contribute to the risk of VA‐LRTI development. This was also recently presented in a French retrospective cohort study showing a threefold increase in risk for VAP in patients that received dexamethasone, with a VAP incidence of 51% 29 . The RECOVERY study group recently reported results of high‐dose dexamethasone versus standard of care (including regular dose dexamethasone), demonstrating increased mortality and bacterial pneumonia in the treatment group compared to standard of care among hypoxic patients not requiring ventilatory support 30 .…”

“…This was also recently presented in a French retrospective cohort study showing a threefold increase in risk for VAP in patients that received dexamethasone, with a VAP incidence of 51%. 29 The RECOVERY study group recently reported results of highdose dexamethasone versus standard of care (including regular dose dexamethasone), demonstrating increased mortality and bacterial pneumonia in the treatment group compared to standard of care among hypoxic patients not requiring ventilatory support. 30 Thus, also among COVID-19 patients there is a need to weigh the antiinflammatory benefits of corticosteroid treatment against potential effects in promoting secondary infection.…”