Ventilator-associated pneumonia in critically ill patients with COVID-19 infection: a narrative review.

COVID pneumonitis can cause patients to become critically ill. They may require intensive care and mechanical ventilation. Ventilator-associated pneumonia (VAP) is a concern. This review discusses VAP in this group. Several reasons have been proposed to explain the elevated rates of VAP in critically ill COVID patients compared to non-COVID patients. Extrinsic factors include understaffing, lack of personal protective equipment and use of immunomodulating agents. Intrinsic factors include severe parenchymal damage and immune dysregulation, along with pulmonary vascular endothelial inflammation and thrombosis. The rate of VAP has been reported at 45.4%, with an intensive care unit mortality rate of 42.7%. Multiple challenges to diagnosis exist. Other conditions such as acute respiratory distress syndrome, pulmonary oedema and atelectasis can present with similar features. Frequent growth of gram-negative bacteria has been shown in multiple studies, with particularly high rates of Pseudomonas aeruginosa. The rate of invasive pulmonary aspergillosis has been reported at 4-30%. We would recommend the use of invasive techniques when possible. This will enable de-escalation of antibiotics as soon as possible, decreasing overuse. It is also important to keep other possible causes of VAP in mind, e.g. COVID-19-associated pulmonary aspergillosis or cytomegalovirus. Diagnostic tests such as galactomannan and ß-D-glucan should be considered. These patients may face a long treatment course, with risk of re-infection, along with prolonged weaning, which carries its own long-term consequences.

The Incidence of Venous Thromboembolism in Critically Ill Patients with SARS-CoV-2 Infection Compared with Critically Ill Influenza and Community-Acquired Pneumonia Patients: A Retrospective Chart Review.

The rate of venous thromboembolism in COVID-19 patients has been reported to be 30% (deep vein thrombosis 20% and pulmonary embolism 18%). This has been shown to be higher in COVID-19 patients admitted to the ICU. Prophylactic anticoagulation may be sufficient at ward level, but not in intensive care. A retrospective chart review was undertaken in a large university hospital. The review included 276 patients from COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia groups. The timeframe included patients admitted between 23 February 2014 and 12 May 2021. Clinical characteristics, outcomes, blood results, rates of venous thromboembolism, and anticoagulation status were recorded. The incidence of venous thromboembolism in COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia was 10.91%, 13.69%, 13.33%, and 6.81%, respectively (p = 0.481). The incidence of pulmonary embolism was 7.27%, 10.95%, 3.33%, and 5.68%, respectively (p = 0.350). The incidence of deep vein thrombosis was 5.45%, 5.48%, 10.00%, and 1.14%, respectively (p = 0.117). Although most patients were prophylactically anticoagulated, venous thromboembolism still occurred. Venous thromboembolism remains an important differential to consider in critically ill COVID-19 patients. The current literature does not advise therapeutic anticoagulation for thromboprophylaxis in the ICU.

Elevated Rates of Ventilator-Associated Pneumonia and COVID-19 Associated Pulmonary Aspergillosis in Critically Ill Patients with SARS-CoV2 Infection in the Second Wave: A Retrospective Chart Review.

Due to multiple risk factors, the rate of ventilator-associated pneumonia in critically ill COVID-19 patients has been reported in a range of 7.6% to 86%. The rate of invasive pulmonary aspergillosis in this cohort has been reported at 4% to 30%. We undertook a retrospective chart review of 276 patients who were admitted to intensive care in a large university hospital. The period studied included patients from 23 February 2014 to 12 May 2021. Four groups were collected: COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia. Clinical characteristics, outcomes, and microbiological cultures were recorded. The incidence of ventilator-associated pneumonia in COVID-19 Wave 1, COVID-19 Wave 2, influenza, and community-acquired pneumonia was 5.45%, 27.40%, 16.67%, and 3.41%, respectively (p < 0.001). The rate of invasive pulmonary aspergillosis was 0%, 9.59%, 13.33%, and 6.82%, respectively (p < 0.001). A significantly elevated rate of ventilator-associated pneumonia and invasive pulmonary aspergillosis was noted in the second wave of COVID-19 when compared to the first. This was accompanied by an increase in the mortality rate. Increased steroid use was an independent risk factor for ventilator-associated pneumonia and invasive pulmonary aspergillosis across all four groups. Despite an increased understanding of this disease, no clinical trials have shown any promising therapeutic options at present.

Ventilator-associated pneumonia in critically ill patients with COVID-19 infection, a narrative review

COVID pneumonitis can cause patients to become critically ill. They may require intensive care and mechanical ventilation. Ventilator-associated pneumonia is a concern. This review aims to discuss the topic of ventilator-associated pneumonia in this group. Several reasons have been proposed to explain the elevated rates of VAP in critically ill COVID patients compared to non-COVID patients. Extrinsic factors include understaffing, lack of PPE and use of immunomodulating agents. Intrinsic factors include severe parenchymal damage, immune dysregulation, along with pulmonary vascular endothelial inflammation and thrombosis. The rate of VAP has been reported at 45.4%, with an ICU mortality rate of 42.7%. Multiple challenges to diagnosis exist. Other conditions such as acute respiratory distress syndrome, pulmonary oedema and atelectasis can present with similar features. Frequent growth of gram-negative bacteria has been shown in multiple studies, with particularly high rates of pseudomonas aeruginosa. The rate of invasive pulmonary aspergillosis has been reported at 4–30%. We would recommend the use of invasive techniques when possible. This will enable de-escalation of antibiotics as soon as possible, decreasing overuse. It is also important to keep other possible causes of ventilator-associated pneumonia in mind, such as COVID-19 associated pulmonary aspergillosis, cytomegalovirus, etc. Diagnostic tests such as galactomannan and B-D-glucan should be considered. These patients may face a long treatment course, with risk of re-infection, along with prolonged weaning, which carries its own long-term consequences.

The incidence of venous thromboembolism in critically ill patients with COVID-19 compared with critically ill non-COVID patients.

BACKGROUND: COVID-19 is a novel coronavirus that is currently responsible for the global pandemic. It has been reported that up to 25% [1] of hospitalized patients with COVID-19 develop VTE (venous thromboembolism), and this can be as high as 31% in ICU patients with COVID-19 [2]. AIMS: To determine VTE rates in ICU patients with COVID compared to those admitted with influenza and a control group. METHODS: We performed a retrospective chart review of 113 patients admitted to ICU at our hospital. Patient characteristics, comorbidities, coagulation profile and prevalence of radiologically proven VTE were recorded and compared between groups. RESULTS: More males than females were found in each group. When groups were compared the mean age, BMI and cigarette smoking were similar, as was the incidence of diabetes, chronic obstructive pulmonary disease and chronic kidney disease. aPTT was higher in the COVID-19 (30.9 ± 3.7 SD) vs (12.8 ± 4.1 SD) the influenza group vs (15.2 ± 4.1 SD) in controls p < 0.001, but fibrinogen was lower 6.2 ± 1.6 SD vs 34.6 ± 14.0SD vs 30.8 ± 5.0 SD, respectively, p < 0.001. VTE rates in the COVID (13.2%) (DVT 5.3%, PE 10.5%) and influenza groups (15.8%) (DVT 13.2%, PE 2.6%) were similar but were higher than the control group (8.1%) (DVT 8.1%, PE 2.7%), but not significantly so (p = 0.5). CONCLUSIONS: ICU patients with COVID-19 displayed an abnormal coagulation profile and a VTE rate that is similar to ICU patients with influenza. VTE occurred despite thromboprophylaxis and remains a pertinent differential to keep in mind.