Chest
Volume 160, Issue 2, August 2021, Pages 454-465
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Chest Infections: Original Research
Hospital-Acquired Infections in Critically Ill Patients With COVID-19

https://doi.org/10.1016/j.chest.2021.04.002Get rights and content

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

Key Words

COVID-19
critical care
hospital-acquired infections
SARS-CoV-2

Abbreviations

BSI
blood stream infection
HAI
hospital-acquired infection
IMV
invasive mechanical ventilation
IQR
interquartile range
LOS
length of stay
MDR
multidrug-resistant
VAP
ventilator-associated pneumonia

Cited by (0)

Drs Grasselli and Scaravilli contributed equally to this manuscript.

FUNDING/SUPPORT: This work was partly funded by the Italian Ministry of Health, grant Ricerca Finalizzata [Grant COVID-2020-12371675: “COVID19: epidemiological, clinical, genetic, and social determinants of infection and disease progression”].

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