Ventilator-associated pneumonia in critically ill patients with COVID-19 infection: a narrative review

Abstract

COVID pneumonitis can cause patients to become critically ill. They may require intensive care and mechanical ventilation. Ventilator-associated pneumonia is a concern. This review aims to discuss the topic of ventilator-associated pneumonia in this group. Several reasons have been proposed to explain the elevated rates of VAP in critically ill COVID patients compared to non-COVID patients. Extrinsic factors include understaffing, lack of PPE and use of immunomodulating agents. Intrinsic factors include severe parenchymal damage, immune dysregulation, along with pulmonary vascular endothelial inflammation and thrombosis. The rate of VAP has been reported at 45.4%, with an ICU mortality rate of 42.7%. Multiple challenges to diagnosis exist. Other conditions such as acute respiratory distress syndrome, pulmonary oedema and atelectasis can present with similar features. Frequent growth of gram-negative bacteria has been shown in multiple studies, with particularly high rates of pseudomonas aeruginosa. The rate of invasive pulmonary aspergillosis has been reported at 4–30%. We would recommend the use of invasive techniques when possible. This will enable de-escalation of antibiotics as soon as possible, decreasing overuse. It is also important to keep other possible causes of ventilator-associated pneumonia in mind, such as COVID-19 associated pulmonary aspergillosis, cytomegalovirus, etc. Diagnostic tests such as galactomannan and B-D-glucan should be considered. These patients may face a long treatment course, with risk of re-infection, along with prolonged weaning, which carries its own long-term consequences.

Ventilator-Associated Pneumonia in COVID-19 Patients Admitted in Intensive Care Units: Relapse, Therapeutic Failure and Attributable Mortality—A Multicentric Observational Study from the OutcomeRea Network

“…In addition, Giacobbe et al estimated the attributable mortality of VAP was about 50%, and patients showed a doubling in length of stay [ 11 ]. The rate of VAP recurrences varied from 23% to 37% according to studies comparing viral and non-viral ARDS [ 12 , 13 , 14 ]. Moreover, treatment failures occurred in up to 66% of COVID-19 patients under extracorporeal membrane oxygenation (ECMO) [ 15 ], and severe complications, such as lung abscesses, were frequently diagnosed [ 16 , 17 ].…”

Bacterial pneumonia associated with multidrug-resistant Gram-negative pathogens: Understanding epidemiology, resistance patterns, and implications with COVID-19

“…111,112 In general, the rates of VAP in patients with COVID-19 who were critically ill was reported to rise above 50%, [113][114][115][116][117] with an estimated mortality exceeding 40%, and an increase in the number of patients requiring intensive care. 118 In a multicenter study, VAP accounted for 50% of all hospital-acquired infections in patients with COVID-19, with 28% prevalence of Gram-negative pathogens as agents in VAP. 119 In another case series, 2% of HAP and 33% of VAP were documented among COVID-19 patients admitted to the ICU, with VAP resulting in more acute respiratory distress syndrome (ARDS), and being associated with more acute kidney injury, long mechanical ventilation longer, and longer ICU stay.…”

Mortality, incidence, and microbiological documentation of ventilated acquired pneumonia (VAP) in critically ill patients with COVID-19 or influenza

“…Several studies have reported data on the epidemiology and consequences of bacterial VAP in patients with COVID-19 [ 5 – 7 ] or H1N1 influenza [ 8 ], most of which concerned risk factors, length of hospital stay and mortality [ 5 – 7 ]. Few comparisons were made between the two viruses regarding the occurrence of VAP.…”