Co-infection and ICU-acquired infection in COVID-19 ICU patients: a secondary analysis of the UNITE-COVID data set
Andrew Conway Morris, Katharina Köhler, Thomas De Corte, Ari Ercole, Harm‐Jan de Grooth, Paul Elbers, Pedro Póvoa, Rui Morais, Despoina Koulenti, Sameer Jog, Nathan D. Nielsen, Alasdair Jubb, Maurizio Cecconi, Jan J. De Waele, for the ESICM UNITE COVID investigators, Marco Bezzi, Alicia Gira, Philipp Eller, Tarikul Hamid, Injamam Ull Haque, Wim De Buyser, Antonella Cudia, Daniel De Backer, Pierre Foulon, Vincent Collin, Jan J. De Waele, Jolien Van Hecke, Elisabeth De Waele, Claire Van Malderen, Jean-Baptiste Mesland, Michaël Piagnerelli, Lionel Haentjens, Nicolas De Schryver, Jan Van Leemput, Philippe Vanhove, Pierre Bulpa, Viktoria Ilieva, David Katz, Anna Geagea, Alexandra Binnie, Fernando Tirapegui, Gustavo Lago, Jerónimo Graf, Rodrigo Perez-Araos, Patricio Vargas, Felipe Martínez, Eduardo Labarca, Daniel Franco, Daniela Parra-Tanoux, Luis Felipe Reyes, David Yepes, Filip Periš, Sanda Stojanović Stipić, Cynthia Vanessa Campozano Burgos, Paulo Roberto Navas Boada, Jose Luis Barberan Brun, Juan Pablo Paredes Ballesteros, Ahmed Hammouda, Omar Elmandouh, Ahmed Y. Azzam, Aliae Mohamed Hussein, Islam Galal, Ahmed K. Awad, Mohammed A. Azab, Maged Abdalla, Hebatallah Hany Assal, Mostafa Alfishawy, Sherief Ghozy, Samar Tharwat, Abdullah Eldaly, Veronika Reinhard, Anne Chrisment, Chrystelle Poyat, Julio Badié, Fernando Berdaguer Ferrari, Björn Weiß, Karl Friedrich Kuhn, Julius J. Grunow, Marco Lorenz, Stefan J. Schaller, Peter Spieth, Marc Bota, Falk Fichtner, Kristina Fuest, Tobias Lahmer, Johannes Herrmann, Patrick Meybohm, Νικόλαος Μάρκου, Georgia Vasileiadou, Evangelia Chrysanthopoulou, Panagiotis Papamichalis, Ioanna Soultati, Sameer Jog, Kushal Kalvit, Sheila Nainan Myatra, Ivan Krupa, Aisa Tharwat, Alistair Nichol, Aine McCarthy, Ata Mahmoodpoor
Abstract
BACKGROUND: The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients. METHODS: This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson's Chi-squared and continuous variables by Mann-Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the "full" matching method. RESULTS: Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO. CONCLUSIONS: In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021).