Risk factors and effect on mortality of superinfections in a newly established COVID-19 respiratory sub-intensive care unit at University Hospital in Rome

Real-world evaluation of imipenem/cilastatin/relebactam across US medical centres

We assessed 160 patients who received imipenem/cilastatin/relebactam for ≥2 days. At treatment initiation, the median Charlson Comorbidity Index was 5, 45% were in the intensive care unit, and 19% required vasopressor support. The in-hospital mortality rate was 24%. These data advance our understanding of real-world indications and outcomes of imipenem/cilastatin/relebactam use.

Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

INTRODUCTION

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

METHODS

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

RESULTS

A total of 284 patients were included, most were male (66.9%), aged 30-50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the 'Watch' category (90.8%) followed by the 'Reserve' category (4.8%), similar to previous COVID-19 waves.

CONCLUSION

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

Bacterial Community- and Hospital-Acquired Pneumonia in Patients with Critical COVID-19-A Prospective Monocentric Cohort Study

The impact of bacterial pneumonia on patients with COVID-19 infection remains unclear. This prospective observational monocentric cohort study aims to determine the incidence of bacterial community- and hospital-acquired pneumonia (CAP and HAP) and its effect on mortality in critically ill COVID-19 patients admitted to the intensive care unit (ICU) at University Hospital Olomouc between 1 November 2020 and 31 December 2022. The secondary objectives of this study include identifying the bacterial etiology of CAP and HAP and exploring the capabilities of diagnostic tools, with a focus on inflammatory biomarkers. Data were collected from the electronic information hospital system, encompassing biomarkers, microbiological findings, and daily visit records, and subsequently evaluated by ICU physicians and clinical microbiologists. Out of 171 patients suffering from critical COVID-19, 46 (27%) had CAP, while 78 (46%) developed HAP. Critically ill COVID-19 patients who experienced bacterial CAP and HAP exhibited higher mortality compared to COVID-19 patients without any bacterial infection, with rates of 38% and 56% versus 11%, respectively. In CAP, the most frequent causative agents were chlamydophila and mycoplasma; Enterobacterales, which were multidrug-resistant in 71% of cases; Gram-negative non-fermenting rods; and Staphylococcus aureus. Notably, no strains of Streptococcus pneumoniae were detected, and only a single strain each of Haemophilus influenzae and Moraxella catarrhalis was isolated. The most frequent etiologic agents causing HAP were Enterobacterales and Gram-negative non-fermenting rods. Based on the presented results, commonly used biochemical markers demonstrated poor predictive and diagnostic accuracy. To confirm the diagnosis of bacterial CAP in our patient cohort, it was necessary to assess the initial values of inflammatory markers (particularly procalcitonin), consider clinical signs indicative of bacterial infection, and/or rely on positive microbiological findings. For HAP diagnostics, it was appropriate to conduct regular detailed clinical examinations (with a focus on evaluating respiratory functions) and closely monitor the dynamics of inflammatory markers (preferably Interleukin-6).

Secondary pulmonary infection and co-infection in elderly COVID-19 patients during the pandemics in a tertiary general hospital in Beijing, China

Background

Most people are infected with COVID-19 during pandemics at the end of 2022. Older patients were more vulnerable. However, the incidence of secondary bacterial, fungal or viral pulmonary infection and co-infection is not well described in elderly hospitalized COVID-19 patients.

Methods

We retrospectively reviewed the medical records of all elderly (≥65 years) hospitalized patients with laboratory-confirmed COVID-19 from December 1, 2022 to January 31, 2023. Demographics, underlying diseases, treatments, and laboratory data were collected. Univariate and multivariate logistic regression models were used to explore the risk factors associated with secondary bacterial, fungal or viral pulmonary infection and co-infection.

Results

A total of 322 older patients with COVID-19 were enrolled. The incidence of secondary bacterial, fungal or viral pulmonary infection and co-infection was 27.3% (88/322) and 7.5% (24/322), respectively. The overall in-hospital mortality of all patients was 32.9% (106/322), and the in-hospital mortality among patients who acquired with secondary pulmonary infection and co-infection was 57.0% (57/100). A total of 23.9% (77/322) of patients were admitted to ICU within 48 h of hospitalization. The incidence of secondary pulmonary infection and co-infection among patients admitted to the ICU was 50.6% (39/77) and 13.0% (10/77), respectively. The overall in-hospital mortality of ICU patients was 48.1% (37/77), and the in-hospital mortality of ICU patients acquired with secondary pulmonary infection and co-infection was 61.4% (27/44). A total of 83.5% (269/322) of the included patients received empirical antibiotic therapy before positive Clinical Microbiology results. Influenza A virus (the vast majority were the H3N2 subtype) was the most common community acquired pathogen for co-infection. While A. baumannii, K. pneumoniae, and P. aeruginosa were the common hospital acquired pathogens for co-infection and secondary pulmonary infection. The incidence of Carbapenem-resistant Gram-negative bacilli (CR-GNB) infections was high, and the mortality reached 76.9%. Predictors of secondary pulmonary infection and co-infection were ICU admission within 48 h of hospitalization, cerebrovascular diseases, critical COVID-19, and PCT > 0.5 ng/mL.

Conclusion

The prognosis for elderly hospitalized COVID-19 patients with secondary pulmonary infection or co-infection is poor. The inflammatory biomarker PCT > 0.5 ng/mL played an important role in the early prediction of secondary pulmonary infection and co-infection in COVID-19 patients.

Prevalence and Impact on Mortality of Colonization and Super-Infection by Carbapenem-Resistant Gram-Negative Organisms in COVID-19 Hospitalized Patients

BACKGROUND

The relationship between superinfection by multidrug-resistant Gram-negative bacteria and mortality among SARS-CoV-2 hospitalized patients is still unclear. Carbapenem-resistant Acinetobacter baumannii and carbapenemase-producing Enterobacterales are among the most frequently isolated species when it comes to hospital-acquired superinfections among SARS-CoV-2 patients.

METHODS

Herein, a retrospective study was carried out using data from adult patients hospitalized for COVID-19. The interaction between in-hospital mortality and rectal carriage and superinfection by carbapenemase-producing Enterobacterales and/or carbapenem-resistant Acinetobacter baumannii was assessed.

RESULTS

The incidence of KPC-producing Klebsiella pneumoniae and/or carbapenem-resistant Acinetobacter baumannii rectal carriage was 30%. Bloodstream infection and/or pneumonia due to KPC-producing Klebsiella pneumoniae and/or carbapenem-resistant Acinetobacter baumannii occurred in 20% of patients. A higher Charlson comorbidity index (OR 1.41, 95% CI 1.24-1.59), being submitted to invasive mechanical ventilation/ECMO ≥ 96 h (OR 6.34, 95% CI 3.18-12.62), being treated with systemic corticosteroids (OR 4.67, 95% CI 2.43-9.05) and having lymphopenia at the time of admission (OR 0.54, 95% CI 0.40-0.72) were the features most strongly associated with in-hospital mortality.

CONCLUSIONS

Although KPC-producing Klebsiella pneumoniae and/or carbapenem-resistant Acinetobacter baumannii rectal carriage, and/or bloodstream infection/pneumonia were diagnosed in a remarkable percentage of COVID-19 patients, their impact on in-hospital mortality was not significant. Further studies are needed to assess the burden of antimicrobial resistance as a legacy of COVID-19 in order to identify future prevention opportunities.

Characteristics and risk factors of secondary bacterial infections in COVID-19 patients

Objective

To describe the characteristics and find out risk factors of COVID-19 patients infected with different categories of bacteria.

Design

Case-control.

Methods

We conducted a retrospective study including 129 COVID-19 patients admitted to a tertiary hospital between October 13, 2022 and December 31, 2022. Patients' data were collected from the hospital information system. Patients were classified as having or not having confirmed secondary bacterial infections, or gram-positive and gram-negative bacterial infections for analysis. Categories and sources of isolated bacteria, characteristics of the patients, and the risk factors for developing secondary bacterial infections were analyzed.

Results

Gram-negative bacteria accounted for the majority of secondary bacterial infections of the included patients. Critical type of COVID-19 (OR = 12.98, 95%CI 3.43∼49.18, p < 0.001), invasive therapy (OR = 9.96, 95%CI 3.01∼32.95, p < 0.001), and previous antibiotics use (OR = 17.23, 95%CI 1.38∼215.69, p = 0.027) were independent risk factors of secondary bacterial infections in COVID-19 patients. Ceftriaxone/cefotaxime use (OR = 15.45, 95%CI 2.72∼87.79, p = 0.002) was associated with gram-positive bacterial infections while age over 70 (OR = 3.30, 95%CI 1.06∼10.26, p = 0.039), invasive therapy (OR = 4.68, 95%CI 1.22∼17.93, p = 0.024), and carbapenems use (OR = 8.48, 95%CI 2.17∼33.15, p = 0.002) were associated with gram-negative bacterial infections.

Conclusions

Critical patients with invasive therapy and previous antibiotics use should be cautious with secondary bacterial infections. Third-generation cephalosporins and carbapenems should be used carefully because both are risk factors for gram-positive or gram-negative bacterial infections.

Identification of risk factors and development of a predictive model for bloodstream infection in intensive care unit COVID-19 patients

OBJECTIVES

To identify risk factors for nosocomial bloodstream infections (BSIs) in intensive care unit (ICU) patients with COVID-19 and to build a predictive model for BSIs.

PATIENTS AND METHODS

The retrospective case-control study included 236 ICU COVID-19 patients with BSIs group and 234 patients in the control group. Demographic and laboratory data, comorbidities, drug use, invasive procedures and identified pathogens were recorded separately for patients directly admitted and transferred to ICU. Fine and Gray's multi-variate competing risk model was used to build a predictive model for patients transferred to ICU.

RESULTS

The risk factors were: interleukin inhibitors (HR = 6.1 (95% CI: 2.0-18.5)) and dexamethasone (HR = 3.0 (95% CI: 1.3-7.1)) use in previous hospitalization, glomerular filtration rate <60 mL/min per 1.73 m2 (HR = 4.0 (95% CI: 2.1-7.6)) and blood glucose >9 mmol/L (HR = 2.5 (95% CI: 1.4-4.6)) in patients directly admitted to ICU; and dexamethasone use in previous hospitalization (HR = 4.5 (95% CI: 1.8-11)), the total dexamethasone dose before transfer to ICU (HR = 1.2 (95% CI: 1.06-1.37)), diabetes mellitus (HR = 1.4 (95% CI: 1.1-1.9)), alanine transaminase (ALT) ≥35.5 U/L on hospital admission (HR = 1.5 (95% CI: 1.1-2.1)), and the use of low-flow oxygen versus high-flow oxygen therapy or non-invasive mechanical ventilation on admission to ICU ((HR = 2.7 (95% CI: 5.6-11.1)) in patients transferred to ICU. A predictive model had sensitivity of 63-73% and specificity of 71-83% at different times of ICU stay.

CONCLUSIONS

Our findings may help clinicians detect patients at high risk of developing BSIs.

Antibiotic-Resistant ESKAPE Pathogens and COVID-19: The Pandemic beyond the Pandemic

Antibacterial resistance is a renewed public health plague in modern times, and the COVID-19 pandemic has rekindled this problem. Changes in antibiotic prescribing behavior, misinformation, financial hardship, environmental impact, and governance gaps have generally enhanced the misuse and improper access to antibiotics during the COVID-19 pandemic. These determinants, intersected with antibacterial resistance in the current pandemic, may amplify the potential for a future antibacterial resistance pandemic. The occurrence of infections with multidrug-resistant (MDR), extensively drug-resistant (XDR), difficult-to-treat drug-resistant (DTR), carbapenem-resistant (CR), and pan-drug-resistant (PDR) bacteria is still increasing. The aim of this review is to highlight the state of the art of antibacterial resistance worldwide, focusing on the most important pathogens, namely Enterobacterales, Acinetobacter baumannii, and Klebsiella pneumoniae, and their resistance to the most common antibiotics.

Prevalence and mortality rate of healthcare-associated infections among COVID-19 patients: a retrospective cohort community-based approach

Background

The prevalence of HAI among COVID-19 patients ranged between 4.8% and 42.8% with the highest occurrence observed in critically ill patients. The present study aimed to evaluate the clinical features of HAI in severe and critical COVID-19 patients, their microbiological characteristics, and the attributable risk factors.

Methods

This is an analytical observational, retrospective single-center, cohort study that included 723 patients with severe-critical COVID-19 admitted to Saint George Hospital between September 2020 and February 2021. Data collection included demographic variables (sex, age), comorbidities, laboratory findings, HAI types and agents, COVID-19 treatment modalities, hospitalization settings, length of stay, and mortality rate. Data was analyzed using SPSS version 25.

Results

The prevalence of patients developing HAI was 7.3% (53 of 723). Five types of nosocomial bacterial infections were tracked noting ventilator-associated pneumonia (41.26%), catheter-associated urinary tract infection (28.6%), hospital-acquired pneumonia (17.44%), catheter-related bloodstream infection (6.35%), and bloodstream infection (6.35%). Binary logistic analysis showed that HAI are statistically affected by four factors noting patients' age (p = 0.039), Length of Stay (p < 0.001), BIPAP (p = 0.019), and mechanical ventilation (p < 0.001). The risk of having HAI increases 3.930 times in case of mechanical ventilation, 2.366 times in case of BIPAP, 1.148 times when the LOS increases 1 day, and 1.029 times when the age is higher with 1 year.

Conclusion

Since the prevalence of HAI is high among severe and critical COVID-19 patients, it is important to prepare a treatment with diagnostic, preventative, and control measures for this infection.

Risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections and related mortality in critically ill patients with CRAB colonization

Background

Among MDR bacteria, carbapenem-resistant Acinetobacter baumannii (CRAB) is a major concern due to the limited therapeutic options. During the COVID-19 pandemic, a worrying increase in the spread of CRAB infections was reported.

Objectives

The study assessed the risk factors for CRAB bloodstream infection (BSI) in patients admitted to the ICU with CRAB colonization, and the related mortality risk factors.

Methods

We conducted a single-centre, observational, prospective study; all consecutive patients with CRAB colonization admitted to the ICU of a tertiary hospital in Rome from January 2021 to September 2022 were included in the study. Univariate and multivariate analyses were performed to investigate BSI and mortality risk factors.

Results

Overall, 129 patients were included in the study; 57 (44%) out of these developed BSI. In our study population, at the multivariable analysis the Charlson comorbidity index (CCI) (P = 0.026), COVID-19 (P < 0.001), multisite colonization (P = 0.016) and the need for mechanical ventilation (P = 0.024) were risk factors independently associated with BSI development. Furthermore, age (P = 0.026), CCI (P < 0.001), septic shock (P = 0.001) and Pitt score (P < 0.001) were independently associated with mortality in the BSI patients. Instead, early appropriate therapy (P = 0.002) and clinical improvement within 72 h (P = 0.011) were shown to be protective factors.

Conclusions

In critically ill patients colonized by CRAB, higher CCI, multisite colonization and the need for mechanical ventilation were identified as risk factors for BSI onset. These predictors could be useful to identify patients at highest risk of BSI.

Acinetobacter baumannii in the critically ill: complex infections get complicated

Acinetobacter baumannii is increasingly associated with various epidemics, representing a serious concern due to the broad level of antimicrobial resistance and clinical manifestations. During the last decades, A. baumannii has emerged as a major pathogen in vulnerable and critically ill patients. Bacteremia, pneumonia, urinary tract, and skin and soft tissue infections are the most common presentations of A. baumannii, with attributable mortality rates approaching 35%. Carbapenems have been considered the first choice to treat A. baumannii infections. However, due to the widespread prevalence of carbapenem-resistant A. baumannii (CRAB), colistin represents the main therapeutic option, while the role of the new siderophore cephalosporin cefiderocol still needs to be ascertained. Furthermore, high clinical failure rates have been reported for colistin monotherapy when used to treat CRAB infections. Thus, the most effective antibiotic combination remains disputed. In addition to its ability to develop antibiotic resistance, A. baumannii is also known to form biofilm on medical devices, including central venous catheters or endotracheal tubes. Thus, the worrisome spread of biofilm-producing strains in multidrug-resistant populations of A. baumannii poses a significant treatment challenge. This review provides an updated account of antimicrobial resistance patterns and biofilm-mediated tolerance in A. baumannii infections with a special focus on fragile and critically ill patients.

Inhalation phage therapy as a new approach to preventing secondary bacterial pneumonia in patients with moderate to severe COVID-19: A double-blind clinical trial study

Inhalation phage therapy is proposed as a replacement approach for antibiotics in the treatment of pulmonary bacterial infections. This study investigates phage therapy on bacterial pneumonia in patients with moderate to severe COVID-19 via the inhalation route. In this double-blind clinical trial, 60 patients with positive COVID-19 hospitalized in three central Mazandaran hospitals were chosen and randomly divided into two intervention and control groups. Standard country protocol drugs plus 10 mL of phage suspension every 12 h with a mesh nebulizer was prescribed for 7 days in the intervention group. The two groups were compared in terms of O₂Sat, survival rate, severe secondary pulmonary bacterial infection and duration of hospitalization. Comparing the results between the intervention and control group, in terms of the trend of O₂Sat change, negative sputum culture, no fever, no dyspnea, duration of hospitalization, duration of intubation and under ventilation, showed that the difference between these two groups was statistically different (P value < 0.05). In conclusion, inhalation phage therapy may have a potential effect on secondary infection and in the outcome of COVID-19 patients. However, more clinical trials with control confounding factors are needed to further support this concept.

The impact of bacterial superinfections on the outcome of critically ill patients with COVID-19 associated acute respiratory distress syndrome (ARDS) - a single-centre, observational cohort study

INTRODUCTION

Bacterial superinfections are common in severely ill COVID-19 patients and could be associated with a significant increase in morbidity and mortality.

MATERIAL AND METHODS

We assessed 29 critically ill patients treated in a university hospital's intensive care unit (ICU). Each patient required mechanical ventilation due to COVID-19-induced acute respiratory distress syndrome (ARDS). Fifteen patients who required venovenous extracorporeal membrane oxygenation (VV-ECMO) support (ECMO group) were compared to a control group (CON group) of 14 individuals without ECMO. This study aimed to assess the prevalence of superinfection in both studied groups. Moreover, we evaluated mortality, length of stay in the ICU, positive culture results, antibiotics used during treatment, and the impact of immunomodulatory drugs on secondary infections.

RESULTS

We did not find a difference in the number of superinfections between the ECMO and CON groups (11 vs. 10, P = 1.0). The mortality rate was 67% in the ECMO group and 64% in the CON group ( P = 1.0). The patients in both groups had similar numbers of positive culture results and days in the ICU prior to the detection of a positive culture. Antibiotics were administered to ten patients in the ECMO and eight patients in the CON group. The mortality rate was 81% in patients with superinfection versus 25% in those without co-infection ( P = 0.009). We found a negative impact of urea concentration on mortality in our cohort, with an odds ratio of 0.942 (0.891-0.996, P = 0.034).

CONCLUSIONS

Our results suggest that bacterial superinfection in COVID-19 patients negatively impacted survival in the ICU. VV-ECMO support in COVID-19 patients does not seem to improve the outcomes of patients with severe ARDS.