Ventilator-associated pneumonia in patients with SARS-CoV-2-associated acute respiratory distress syndrome requiring ECMO: a retrospective cohort study

Abstract

Background The data on incidence, clinical presentation, and outcomes of ventilator-associated pneumonia (VAP) in patients with severe coronavirus disease 2019 (COVID-19) pneumonia requiring mechanical ventilation (MV) are limited. We performed this retrospective cohort study to assess frequency, clinical characteristics, responsible pathogens, and outcomes of VAP in patients COVID-19 pneumonia requiring MV between March 12th and April 24th, 2020 (all had RT-PCR-confirmed SARS-CoV-2 infection). Patients with COVID-19-associated acute respiratory distress syndrome (ARDS) requiring ECMO were compared with an historical cohort of 45 patients with severe influenza-associated ARDS requiring ECMO admitted to the same ICU during the preceding three winter seasons. Results Among 50 consecutive patients with Covid-19-associated ARDS requiring ECMO included [median (IQR) age 48 (42–56) years; 72% male], 43 (86%) developed VAP [median (IQR) MV duration before the first episode, 10 (8–16) days]. VAP-causative pathogens were predominantly Enterobacteriaceae (70%), particularly inducible AmpC-cephalosporinase producers (40%), followed by Pseudomonas aeruginosa (37%). VAP recurred in 34 (79%) patients and 17 (34%) died. Most recurrences were relapses (i.e., infection with the same pathogen), with a high percentage occurring on adequate antimicrobial treatment. Estimated cumulative incidence of VAP, taking into account death and extubation as competing events, was significantly higher in Covid-19 patients than in influenza patients (p = 0.002). Despite a high P. aeruginosa-VAP rate in patients with influenza-associated ARDS (54%), the pulmonary infection recurrence rate was significantly lower than in Covid-19 patients. Overall mortality was similar for the two groups. Conclusions Patients with severe Covid-19-associated ARDS requiring ECMO had a very high late-onset VAP rate. Inducible AmpC-cephalosporinase-producing Enterobacteriaceae and Pseudomonas aeruginosa frequently caused VAP, with multiple recurrences and difficulties eradicating the pathogen from the lung.

Ventilator-associated pneumonia in critically ill patients with COVID-19

“…Reports of rates of VAP amongst ventilated patients with COVID-19 vary, with rates of 40–86% reported [ 38 – 40 ] and our reported rate of 49% is in keeping with reports from other centres. Although some reports, not focussed specifically on VAP, indicate lower rates of 10% [ 8 ], it is unclear how many of the ICU patients in that cohort were ventilated for at least 48 h. The rates of VAP between centres managing COVID-19 are likely to vary depending on the clinical characteristics of the patients managed, differential ICU admissions policies and clinical factors such as use of immunosuppressive therapies.…”

A Tale of a Two Waves Epidemic: Characteristics and Mortality Risk Factors for COVID-19 ICU Patients in the French West Indies

“…In univariate analysis, VAP occurrence was associated with higher mortality. Its increased frequency in COVID-19 patients compared to standard ARDS patients has been previously described 18,19 . Consistent with these datas, our incidence of VAP in IMV patients was very high (50%), with no statistical differences between the two periods however the length of IMV was longer during the second wave.…”

“…Independent of COVID-19, poor prognosis after failure of NIV has already been described in ARDS patients 20 and with a potentially worsening of lung damage due to self-in icted lung injury 21 . In this pandemic, NIV has been recommended by other authors for COVID-19 pneumonia management 19 , but we believe that this should be done with caution with early reappraisal to avoid late IMV Secondly, besides this physiological explanation, we believe that such grim outcomes could also re ect the pulmonary brotic evolution of COVID-19 pneumonia. This pathological nding has already been described in earlier reports 22,23 .…”

Increased susceptibility to intensive care unit-acquired pneumonia in severe COVID-19 patients: a multicentre retrospective cohort study

“…Other studies have already reported various frequency rates of ICU-acquired pneumonia in mechanically ventilated COVID-19 patients, with estimated incidence ranging from 16 to 31% in two early reports from China [11,12]. Since then, several studies confirmed this impression [13][14][15][16]. Importantly, an accurate estimation for the cumulative risk of ICU-acquired pneumonia in ventilated patient requires handling two main competing events that are extubation and death to avoid misinterpretation of risks.…”