Hospital-Acquired Infections in Critically Ill Patients With COVID-19

Giacomo Grasselli, Vittorio Scaravilli, Davide Mangioni, Luigia Scudeller, Laura Alagna, Michele Bartoletti, Giacomo Bellani, Emanuela Biagioni, Paolo Bonfanti, Nicola Bottino, Irene Coloretti, Salvatore Lucio Cutuli, Gennaro De Pascale, Daniela Ferlicca, Gabriele Fior, Andrea Forastieri, Marco Franzetti, Massimiliano Greco, Amedeo Guzzardella, Sara Linguadoca, Marianna Meschiari, Antonio Messina, Gianpaola Monti, Paola Morelli, Antonio Muscatello, Simone Redaelli, Flavia Stefanini, Tommaso Tonetti, Massimo Antonelli, Maurizio Cecconi, Giuseppe Foti, Roberto Fumagalli, Massimo Girardis, Marco Ranieri, Pierluigi Viale, Mario Raviglione, Antonio Pesenti, Andrea Gori, Alessandra Bandera, Giacomo Grasselli, Vittorio Scaravilli, Davide Mangioni, Luigia Scudeller, Laura Alagna, Michele Bartoletti, Giacomo Bellani, Emanuela Biagioni, Paolo Bonfanti, Nicola Bottino, Irene Coloretti, Salvatore Lucio Cutuli, Gennaro De Pascale, Daniela Ferlicca, Gabriele Fior, Andrea Forastieri, Marco Franzetti, Massimiliano Greco, Amedeo Guzzardella, Sara Linguadoca, Marianna Meschiari, Antonio Messina, Gianpaola Monti, Paola Morelli, Antonio Muscatello, Simone Redaelli, Flavia Stefanini, Tommaso Tonetti, Massimo Antonelli, Maurizio Cecconi, Giuseppe Foti, Roberto Fumagalli, Massimo Girardis, Marco Ranieri, Pierluigi Viale, Mario Raviglione, Antonio Pesenti, Andrea Gori, Alessandra Bandera

Abstract

Background: Few small studies have described hospital-acquired infections (HAIs) occurring in patients with COVID-19.

Research question: What characteristics in critically ill patients with COVID-19 are associated with HAIs and how are HAIs associated with outcomes in these patients?

Study design and methods: Multicenter retrospective analysis of prospectively collected data including adult patients with severe COVID-19 admitted to eight Italian hub hospitals from February 20, 2020, through May 20, 2020. Descriptive statistics and univariate and multivariate Weibull regression models were used to assess incidence, microbial cause, resistance patterns, risk factors (ie, demographics, comorbidities, exposure to medication), and impact on outcomes (ie, ICU discharge, length of ICU and hospital stays, and duration of mechanical ventilation) of microbiologically confirmed HAIs.

Results: Of the 774 included patients, 359 patients (46%) demonstrated 759 HAIs (44.7 infections/1,000 ICU patient-days; 35% multidrug-resistant [MDR] bacteria). Ventilator-associated pneumonia (VAP; n = 389 [50%]), bloodstream infections (BSIs; n = 183 [34%]), and catheter-related BSIs (n = 74 [10%]) were the most frequent HAIs, with 26.0 (95% CI, 23.6-28.8) VAPs per 1,000 intubation-days, 11.7 (95% CI, 10.1-13.5) BSIs per 1,000 ICU patient-days, and 4.7 (95% CI, 3.8-5.9) catheter-related BSIs per 1,000 ICU patient-days. Gram-negative bacteria (especially Enterobacterales) and Staphylococcus aureus caused 64% and 28% of cases of VAP, respectively. Variables independently associated with infection were age, positive end expiratory pressure, and treatment with broad-spectrum antibiotics at admission. Two hundred thirty-four patients (30%) died in the ICU (15.3 deaths/1,000 ICU patient-days). Patients with HAIs complicated by septic shock showed an almost doubled mortality rate (52% vs 29%), whereas noncomplicated infections did not affect mortality. HAIs prolonged mechanical ventilation (median, 24 days [interquartile range (IQR), 14-39 days] vs 9 days [IQR, 5-13 days]; P < .001), ICU stay (24 days [IQR, 16-41 days] vs 9 days [IQR, 6-14 days]; P = .003), and hospital stay (42 days [IQR, 25-59 days] vs 23 days [IQR, 13-34 days]; P < .001).

Interpretation: Critically ill patients with COVID-19 are at high risk for HAIs, especially VAPs and BSIs resulting from MDR organisms. HAIs prolong mechanical ventilation and hospitalization, and HAIs complicated by septic shock almost double mortality.

Trial registry: ClinicalTrials.gov; No.: NCT04388670; URL: www.clinicaltrials.gov.

Keywords: COVID-19; SARS-CoV-2; critical care; hospital-acquired infections.

Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Line graph showing cumulative incidence function of infection and death.
Figure 2
Figure 2
Kernel density plot (violin plot) showing infection onset time. Black tick marks represent median onset time. ∗P 

References

    1. Grasselli G., Zangrillo A., Zanella A. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy. JAMA. 2020;323(16):1574–1581.
    1. Grasselli G., Greco M., Zanella A. Risk factors associated with mortality among patients with COVID-19 in intensive care units in Lombardy, Italy. JAMA Intern Med. 2020;180(10):1345–1355.
    1. Grasselli G., Pesenti A., Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy. JAMA. 2020;323(16):1545–1546.
    1. Cummings M.J., Baldwin M.R., Abrams D. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020;395(10239):1763–1770.
    1. Gabarre P., Dumas G., Dupont T., Darmon M., Azoulay E., Zafrani L. Acute kidney injury in critically ill patients with COVID-19. Intensive Care Med. 2020;46(7):1339–1348.
    1. Qin C., Zhou L., Hu Z. Dysregulation of immune response in patients with coronavirus. 2019 (COVID-19) in Wuhan, China. Clin Infect Dis. 2020;71(15):762–768.
    1. He Y., Li W., Wang Z., Chen H., Tian L., Liu D. Nosocomial infection among patients with COVID-19: a retrospective data analysis of 918 cases from a single center in Wuhan, China. Infect Control Hosp Epidemiol. 2020;41(8):982–983.
    1. Giacobbe D.R., Battaglini D., Ball L. Bloodstream infections in critically ill patients with COVID-19. Eur J Clin Invest. 2020;50(10):1–8.
    1. Langford B.J., So M., Raybardhan S. Bacterial coinfection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020;26(12):1622–1629.
    1. Yu Y., Xu D., Fu S. Patients with COVID-19 in 19 ICUs in Wuhan, China: a cross-sectional study. Crit Care. 2020;24(1):1–10.
    1. Dudoignon E., Caméléna F., Deniau B. Bacterial pneumonia in COVID-19 critically ill patients: a case series. Clin Infect Dis. 2020;72(5):905–906.
    1. Garcia-Vidal C., Sanjuan G., Moreno-García E. Incidence of coinfections and superinfections in hospitalized patients with COVID-19: a retrospective cohort study. Clin Microbiol Infect. 2021;27(1):83–88.
    1. Ripa M., Galli L., Poli A. Secondary infections in patients hospitalized with COVID-19: incidence and predictive factors. Clin Microbiol Infect. 2020;27(3):451–457.
    1. Bhatt P.J., Shiau S., Brunetti L. Risk factors and outcomes of hospitalized patients with severe coronavirus disease 2019 (COVID-19) and secondary bloodstream infections: a multicenter case-control study. Clin Infect Dis. 2020;53(1):151–159.
    1. Papazian L., Klompas M., Luyt C.E. Ventilator-associated pneumonia in adults: a narrative review. Intensive Care Med. 2020;46(5):888–906.
    1. Hanson KE, Caliendo AM, Arias CA, et al. Infectious Diseases Society of America guidelines on the diagnosis of coronavirus disease 2019 [published online ahead of print June 16, 2020]. Clin Infect Dis. 10.1093/cid/ciaa760
    1. Torres A., Niederman M.S., Chastre J. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J. 2017;50(3):1700582.
    1. Manian F.A. IDSA guidelines for the diagnosis and management of intravascular catheter-related bloodstream infection. Clin Infect Dis. 2009;49(11):1770–1771.
    1. Pappas P.G., Kauffman C.A., Andes D. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(5):503–535.
    1. Hage C.A., Carmona E.M., Epelbaum O. Microbiological laboratory testing in the diagnosis of fungal infections in pulmonary and critical care practice: an official American Thoracic Society clinical practice guideline. Am J Respir Crit Care Med. 2019;200(5):535–550.
    1. Rhodes A., Evans L.E., Alhazzani W. Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock. Intensive Care Med. 2017;43(3):304–377.
    1. Magiorakos A.P., Srinivasan A., Carey R.B. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268–281.
    1. Huang C., Wang Y., Li X. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.
    1. Zhou F., Yu T., Du R. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–1062.
    1. Chen N., Zhou M., Dong X. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507–513.
    1. Goyal P., Choi J.J., Pinheiro L.C. Clinical characteristics of Covid-19 in New York City. N Engl J Med. 2020;382(24):2372–2374.
    1. Vincent J.-L., Rello J., Marshall J. International study of the prevalence and outcomes of infection in intensive care units. JAMA. 2009;302(21):2323.
    1. Grasselli G., Scaravilli V., Bella S.Di. Nosocomial infections during extracorporeal membrane oxygenation. Crit Care Med. 2017;45(10):1726–1733.
    1. Malacarne P., Boccalatte D., Acquarolo A. Epidemiology of nosocomial infection in 125 Italian intensive care units. Minerva Anestesiol. 2010;76(1):13–23.
    1. Nickol M., Ciric J., Falcinelli S., Chertow D., Kindrachuk J. Characterization of host and bacterial contributions to lung barrier dysfunction following coinfection with 2009 pandemic influenza and methicillin resistant Staphylococcus aureus. Viruses. 2019;11(2):116.
    1. Rawson T.M., Moore L.S.P., Zhu N. Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis. 2020;71(9):2459–2468.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit