Bacterial complications in patients with coronavirus infection, new diagnostic and therapeutic possibilities.

We present the case of a young patient who developed pneumonia during the COVID-19 outbreak. The course of the disease with involvement of interstitial lung tissue atypical for bacterial infections, the picture of infection markers could indicate SARS-CoV-2. The patient was tested by PCR method on admission with negative results. Due to the atypical follow-up of the disease, suggesting a severe course of SARS, PCR testing of the material collected by BAL was performed BIOFIRE® FILMARRAY® Pneumonia plus Panel (bioMérieux). Legionella pneumophilla and coronavirus genetic materials were found. We conclude that in the described case there was a bacterial co-infection, paved by virus infection. The similar radiological picture of the two cases of pneumonia, as well as the similar infectious response in the blood, specific for atypical infections, may pose a problem in the differential diagnosis. The study was able to confirm the bacterial etiology of pneumonia and introduce targeted treatment. The patient was discharged from the hospital. We believe that in any case of pneumonia of non-bacterial etiology, extending the diagnosis with a PCR pulmonary panel allows early and effective treatment of patients. In the treatment of patients with pulmonary interstitial lesions in the course of virus infections, one should always keep in mind the possibility of atypical co-infections.

Bacterial Co-infections and Susceptibility patterns among admitted COVID 19 patients during 3rd wave of pandemic, in a Tertiary Care Hospital. Lahore

Objective: To check the Bacterial Co-infections and Susceptibility patterns among admitted COVID-19 patients during 3rd wave of pandemic. Study Design: Descriptive Cross Sectional study. Setting: Department of Microbiology, Combined Military Hospital Lahore Pakistan. Period: May 2021 to August 2021. Material & Methods: Six hundred and twelve COVID-19 positive patients having positive bacterial cultures were processed, Antibiotic susceptibility testing was done by Kirby-Bauer diffusion technique, all antibiotics were reported using breakpoints recommended in clinical and laboratory standards institute (CLSI 2021). Results: Out of 612 patients, 348 (56.9%) were male and 264 (43.2%) were female. Mean age of the patients was 57.2 ± 14.4 years with a range of 22 to 89 years. Bacterial coinfection was present in 70.4% of the patients. Gram negative bacteria (94.4%) were more prevalent in COVID-19 patients as compared to gram positive isolates (5.6%). Antibiotic sensitivity pattern of Staphylococcus aureus showed a high resistance against penicillin, ampicillin, tetracycline and doxycycline. Conclusion: Our study reported a high prevalence of bacterial coinfections in COVID-19 patients infected during the third wave of pandemic. A high percentage of gram negative species were identified in our study population, this could be due to the suppression in the immunity of individuals due to severity of COVID-19 infection and already present Antimicrobial resistance. [ FROM AUTHOR] Copyright of Professional Medical Journal is the property of Professional Medical Journal and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Bacterial and viral infections among adults hospitalized with COVID-19, COVID-NET, 14 states, March 2020-April 2022.

Background: Bacterial and viral infections can occur with SARS-CoV-2 infection, but prevalence, risk factors, and associated clinical outcomes are not fully understood. Methods: We used the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance system, to investigate the occurrence of bacterial and viral infections among hospitalized adults with laboratory-confirmed SARS-CoV-2 infection between March 2020 and April 2022. Clinician-driven testing for bacterial pathogens from sputum, deep respiratory, and sterile sites were included. The demographic and clinical features of those with and without bacterial infections were compared. We also describe the prevalence of viral pathogens including respiratory syncytial virus, rhinovirus/enterovirus, influenza, adenovirus, human metapneumovirus, parainfluenza viruses, and non-SARS-CoV-2 endemic coronaviruses. Results: Among 36 490 hospitalized adults with COVID-19, 53.3% had bacterial cultures taken within 7 days of admission and 6.0% of these had a clinically relevant bacterial pathogen. After adjustment for demographic factors and co-morbidities, bacterial infections in patients with COVID-19 within 7 days of admission were associated with an adjusted relative risk of death 2.3 times that of patients with negative bacterial testing. Staphylococcus aureus and Gram-negative rods were the most frequently isolated bacterial pathogens. Among hospitalized adults with COVID-19, 2766 (7.6%) were tested for seven virus groups. A non-SARS-CoV-2 virus was identified in 0.9% of tested patients. Conclusions: Among patients with clinician-driven testing, 6.0% of adults hospitalized with COVID-19 were identified to have bacterial coinfections and 0.9% were identified to have viral coinfections; identification of a bacterial coinfection within 7 days of admission was associated with increased mortality.

Community-Onset Bacterial Coinfection in Children Critically Ill With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Background: Community-onset bacterial coinfection in adults hospitalized with coronavirus disease 2019 (COVID-19) is reportedly uncommon, though empiric antibiotic use has been high. However, data regarding empiric antibiotic use and bacterial coinfection in children with critical illness from COVID-19 are scarce. Methods: We evaluated children and adolescents aged <19 years admitted to a pediatric intensive care or high-acuity unit for COVID-19 between March and December 2020. Based on qualifying microbiology results from the first 3 days of admission, we adjudicated whether patients had community-onset bacterial coinfection. We compared demographic and clinical characteristics of those who did and did not (1) receive antibiotics and (2) have bacterial coinfection early in admission. Using Poisson regression models, we assessed factors associated with these outcomes. Results: Of the 532 patients, 63.3% received empiric antibiotics, but only 7.1% had bacterial coinfection, and only 3.0% had respiratory bacterial coinfection. In multivariable analyses, empiric antibiotics were more likely to be prescribed for immunocompromised patients (adjusted relative risk [aRR], 1.34 [95% confidence interval {CI}, 1.01-1.79]), those requiring any respiratory support except mechanical ventilation (aRR, 1.41 [95% CI, 1.05-1.90]), or those requiring invasive mechanical ventilation (aRR, 1.83 [95% CI, 1.36-2.47]) (compared with no respiratory support). The presence of a pulmonary comorbidity other than asthma (aRR, 2.31 [95% CI, 1.15-4.62]) was associated with bacterial coinfection. Conclusions: Community-onset bacterial coinfection in children with critical COVID-19 is infrequent, but empiric antibiotics are commonly prescribed. These findings inform antimicrobial use and support rapid de-escalation when evaluation shows coinfection is unlikely.

From Co-Infections to Autoimmune Disease via Hyperactivated Innate Immunity: COVID-19 Autoimmune Coagulopathies, Autoimmune Myocarditis and Multisystem Inflammatory Syndrome in Children.

Neutrophilia and the production of neutrophil extracellular traps (NETs) are two of many measures of increased inflammation in severe COVID-19 that also accompany its autoimmune complications, including coagulopathies, myocarditis and multisystem inflammatory syndrome in children (MIS-C). This paper integrates currently disparate measures of innate hyperactivation in severe COVID-19 and its autoimmune complications, and relates these to SARS-CoV-2 activation of innate immunity. Aggregated data include activation of Toll-like receptors (TLRs), nucleotide-binding oligomerization domain (NOD) receptors, NOD leucine-rich repeat and pyrin-domain-containing receptors (NLRPs), retinoic acid-inducible gene I (RIG-I) and melanoma-differentiation-associated gene 5 (MDA-5). SARS-CoV-2 mainly activates the virus-associated innate receptors TLR3, TLR7, TLR8, NLRP3, RIG-1 and MDA-5. Severe COVID-19, however, is characterized by additional activation of TLR1, TLR2, TLR4, TLR5, TLR6, NOD1 and NOD2, which are primarily responsive to bacterial antigens. The innate activation patterns in autoimmune coagulopathies, myocarditis and Kawasaki disease, or MIS-C, mimic those of severe COVID-19 rather than SARS-CoV-2 alone suggesting that autoimmunity follows combined SARS-CoV-2-bacterial infections. Viral and bacterial receptors are known to synergize to produce the increased inflammation required to support autoimmune disease pathology. Additional studies demonstrate that anti-bacterial antibodies are also required to account for known autoantigen targets in COVID-19 autoimmune complications.

Are bacterial coinfections really rare in COVID-19 intensive care units?

OBJECTIVES: There are limited data about nosocomial coinfections of COVID-19 cases monitored in the intensive care unit. This study aims to investigate coinfections in COVID-19 patients followed in an intensive care unit of a university hospital. METHODS: This study analyzed retrospectively the data of coinfections of 351 COVID-19 patients in the period 28.02.2020-15.01.2021 in a tertiary care intensive care unit in a university hospital. RESULTS: Bacterial coinfections were present in 216 of the 351 cases. One hundred and thirty of these cases were evaluated as nosocomial infections. On the third day the Sequential Organ Failure Assessment Score, usage of invasive mechanical ventilation and presence of septic shock were significantly higher in the coinfected group. The neutrophil/lymphocyte ratio, polymorphonuclear leukocyte count, procalcitonin, ferritin, and blood urea nitrogen values were significantly higher in the coinfection group. White blood cells (WBC) (OR: 1.075, 95% CI 1.032-1.121, p = 0.001) and ICU hospitalization day (OR: 1.114, 95% CI 1.063-1.167, p < 0.001) were found to be independent risk factors for coinfection in the multivariate logistic regression analysis. The rates of hospitalization day on the day of arrival, the 21st day, as well as total mortality (p = 0.004), were significantly higher in the coinfected group. CONCLUSION: Bacterial coinfections of COVID-19 patients in the intensive care unit remain a problem. Identifying the infectious agent, classifying colonizations and infections, and using the proper treatment of antibiotics are of great importance in the case management of COVID-19 patients in the intensive care unit.

Bacterial co-infection and antibiotic stewardship in patients with COVID-19: a systematic review and meta-analysis.

INTRODUCTION: Understanding the proportion of patients with COVID-19 who have respiratory bacterial co-infections and the responsible pathogens is important for managing COVID-19 effectively while ensuring responsible antibiotic use. OBJECTIVE: To estimate the frequency of bacterial co-infection in COVID-19 hospitalized patients and of antibiotic prescribing during the early pandemic period and to appraise the use of antibiotic stewardship criteria. METHODS: Systematic review and meta-analysis was performed using major databases up to May 5, 2021. We included studies that reported proportion/prevalence of bacterial co-infection in hospitalized COVID-19 patients and use of antibiotics. Where available, data on duration and type of antibiotics, adverse events, and any information about antibiotic stewardship policies were also collected. RESULTS: We retrieved 6,798 studies and included 85 studies with data from more than 30,000 patients. The overall prevalence of bacterial co-infection was 11% (95% CI 8% to 16%; 70 studies). When only confirmed bacterial co-infections were included the prevalence was 4% (95% CI 3% to 6%; 20 studies). Overall antibiotic use was 60% (95% CI 52% to 68%; 52 studies). Empirical antibiotic use rate was 62% (95% CI 55% to 69%; 11 studies). Few studies described criteria for stopping antibiotics. CONCLUSION: There is currently insufficient evidence to support widespread empirical use of antibiotics in most hospitalised patients with COVID-19, as the overall proportion of bacterial co-infection is low. Furthermore, as the use of antibiotics during the study period appears to have been largely empirical, clinical guidelines to promote and support more targeted administration of antibiotics in patients admitted to hospital with COVID-19 are required.

Antibiotics Used for COVID-19 In-Patients from an Infectious Disease Ward.

Background: although the prevalence of bacterial co-infections for COVID-19 patients is very low, most patients receive empirical antimicrobial therapy. Furthermore, broad spectrum antibiotics are preferred to narrow spectrum antibiotics. Methods: in order to estimate the excess of antibiotic prescriptions for patients with COVID-19, and to identify the factors that were correlated with the unjustified antibiotic usage, we conducted an observational (cohort) prospective study in patients hospitalized with COVID-19 at the National Institute for Infectious Diseases "Prof. Dr. Matei Bals", Bucharest, on an infectious disease ward, from November 2021 to January 2022. To evaluate the prevalence of bacterial co-infection in these patients, all positive microbiology results and concomitant suspected or confirmed bacterial co-infections, as documented by the treating doctor, were recorded. The patients were grouped in two categories: patients who received antibiotics and those who did not receive antibiotics, justified or not. Results: from the 205 patients enrolled in the study, 83 (40.4%) received antibiotics prior to being admitted to the hospital. 84 patients (41.0%) received antibiotics during their hospitalization; however, only 32 patients (15.6%) had signs and symptoms suggestive of an infection, 19 (9.3%) presented pulmonary consolidation on the computed tomography (CT) scan, 20 (9.7%) patients had leukocytosis, 29 (14.1%) had an increased procalcitonin level and only 22 (10.7%) patients had positive microbiological tests. It was observed that patients treated with antibiotics were older [70 (54−76) vs. 65 (52.5−71.5), p = 0.023, r = 0.159], had a higher Charlson index [4 (2−5) vs. 2 (1−4), p = 0.007, r = 0.189], had a severe/critical COVID-19 disease more frequently [61 (72.6%) vs. 38 (31.4%), p < 0.001, df = 3, X2 = 39.563] and required more oxygen [3 (0−6) vs. 0 (0−2), p < 0.001, r = 0.328]. Conclusion: empirical antibiotic treatment recommendation should be reserved for COVID-19 patients that also had other clinical or paraclinical changes, which suggest a bacterial infection. Further research is needed to better identify patients with bacterial co-infection that should receive antibiotic treatment.

Utilization of Antibiotics for Hospitalized Patients with Severe Coronavirus Disease 2019 in Al-Madinah Al-Munawara, Saudi Arabia: A Retrospective Study.

Background: Most patients admitted to intensive care units (ICUs) with severe Corona Virus Disease 2019 (COVID-19) pneumonia receive antibacterial antibiotics with little evidence of bacterial infections. Objective: This study was designed to review the profiles of patients with severe COVID-19 pneumonia requiring intensive care, the rate of bacterial coinfection, the antibiotics used, and their relation to patient outcomes (death or recovery). Methods: This was a retrospective study that reviewed the medical records of all patients with confirmed COVID-19 (n = 120) severe pneumonia admitted directly from the emergency room to the intensive care unit, at a public hospital during the period from May 2020 to April 2021. The data collected included patients' demographic and laboratory data, comorbidities, antibiotic treatment, and their outcome. Descriptive statistics, bivariate inferential analysis tests (chi-square and unpaired T-Tests) and multivariable binary logistic regression were performed. Results: The mean age of the patients was 56.8 ± 16.5 years old, and among them, 74 (62.7%) were males. Of the included patients, 92 (77.0%) had comorbidities, 76 (63.3%) required mechanical ventilation and 30 (25%) died. All patients received empirical antibiotics for suspected bacterial coinfection. The most common antibiotics used were azithromycin (n = 97, 8%) and imipenem (n = 83, 9%). Ninety patients (75%) were on two empirical antibiotics. Early positive cultures for pathogens were found only in four patients (3.3%), whereas 36 (30%) patients had positive cultures 5-10 days after admission. The most frequently isolated pathogens were Acinetobacter baumannii (n = 16) and coagulase-negative Staphylococci (n = 14). In bivariate analysis empirical treatment with azithromycin resulted in a significantly lower mortality rate (p = 0.023), meanwhile mechanical ventilation, days of stay in intensive care unit, morbidities (e.g., lung disease), linezolid and, vancomycin use associated with mortality (p< 0.05). The adjusted logistic regression, controlling for age and gender, revealed that azithromycin antibiotic was more likely protective from mortality (OR= 0.22, 95%CI 0.06-0.85, p=0.028. However, patients with lung diseases and under mechanical ventilation were 35.21 and 19.57 more likely to die (95%CI =2.84-436.70, p=0.006; 95%CI=2.66-143.85, p=0.003, respectively). Conclusion: Bacterial coinfection with severe COVID-19 pneumonia requiring intensive care was unlikely. The benefit of Azithromycin over other antibiotics could be attributed to its anti-inflammatory properties rather than its antibacterial effect.

Antibiotics Use in COVID-19 Patients: A Systematic Literature Review.

The issue of bacterial infections in COVID-19 patients has received increasing attention among scientists. Antibiotics were widely prescribed during the early phase of the pandemic. We performed a literature review to assess the reasons, evidence and practices on the use of antibiotics in COVID-19 in- and outpatients. Published articles providing data on antibiotics use in COVID-19 patients were identified through computerized literature searches on the MEDLINE and SCOPUS databases. Searching the MEDLINE database, the following search terms were adopted: ((antibiotic) AND (COVID-19)). Searching the SCOPUS database, the following search terms were used: ((antibiotic treatment) AND (COVID-19)). The risk of bias in the included studies was not assessed. Both quantitative and qualitative information were summarized by means of textual descriptions. Five-hundred-ninety-three studies were identified, published from January 2020 to 30 October 2022. Thirty-six studies were included in this systematic review. Of the 36 included studies, 32 studies were on the use of antibiotics in COVID-19 inpatients and 4 on antibiotic use in COVID-19 outpatients. Apart from the studies identified and included in the review, the main recommendations on antibiotic treatment from 5 guidelines for the clinical management of COVID-19 were also summarized in a separate paragraph. Antibiotics should not be prescribed during COVID-19 unless there is a strong clinical suspicion of bacterial coinfection or superinfection.

A Comparative Study of Severe and Critical Influenza B in Children in the 2021-2022 Winter Season.

Introduction: Influenza B viruses are less common than influenza A viruses in most seasons and cause relatively milder forms of infection that are less studied. We witnessed a dominance of influenza B in Shijiazhuang, China, in the 2021-2022 winter season. In this study, we comparatively investigated the severe and critical influenza B in pediatric patients. Methods: Children who were hospitalized from December 2021 to January 2022 and diagnosed with influenza B were included in this study. Those who tested positive for COVID-19 were excluded. Demographic data, clinical features, underlying medical conditions, laboratory testing results, and treatment outcomes were retrieved and analyzed retrospectively. Disease severity was classified as severe or critical according to Chinese expert consensus on diagnosis and treatment of influenza in children. Results: A significantly greater proportion of patients with critical influenza had extra-pulmonary complications and bacterial coinfections. Children with critical influenza B had substantially higher levels of procalcitonin and lactate dehydrogenase, a markedly higher neutrophil percentage and a significantly lower CD4+ lymphocyte percentage. Conclusion: Our findings suggest that, to effectively manage critical influenza B, therapeutic regimens should consist of organ-specific supportive care, antibiotic application if bacterial coinfection is present, and anti-inflammatory and immune-boosting treatments.

Profile of Co-Infection Prevalence and Antibiotics Use among COVID-19 Patients.

Bacterial co-infection in COVID-19 patients significantly contributes to the worsening of the prognosis based on morbidity and mortality. Information on the co-infection profile in such patients could help to optimize treatment. The purpose of this study was to describe bacterial co-infections associated with microbiological, clinical, and laboratory data to reduce or avoid a secondary infection. A retrospective cohort study was conducted at Sant'Anna and San Sebastiano Hospital from January 2020 to December 2021. Bacterial co-infection was detected in 14.3% of the COVID-19-positive patients. The laboratory findings on admission showed significant alterations in the median D-dimer, C-reactive protein, interleukin-6, and lactate dehydrogenase values compared to normal values. All inflammatory markers were significantly elevated. The most common pathogens isolated from blood cultures were E. faecalis and S. aureus. Instead, the high prevalence of respiratory tract infections in the COVID-19 patients was caused by P. aeruginosa (41%). In our study, 220 (82.4%) of the COVID-19 patients received antimicrobial treatment. Aminoglycosides and ß-lactams/ß-lactamase inhibitors showed the highest resistance rates. Our results showed that older age, underlying conditions, and abnormal laboratory parameters can be risk factors for co-infection in COVID-19 patients. The antibiotic susceptibility profile of bacterial pathogen infection provides evidence on the importance, for the clinicians, to rationalize and individualize antibiotic usage.

Beyond Guidelines and Reports on Bacterial Co-/Superinfections in the Context of COVID-19: Why Uniformity Matters.

BACKGROUND: In the period following the declaration of the COVID-19 pandemic, more evidence became available on the epidemiology of bacterial co-/superinfections (bCSs) in hospitalized COVID-19 patients. Various European therapeutic guidelines were published, including guidance on rational antibiotic use. METHODS: In this letter to the editor, we provide an overview of the largest meta-analyses or prospective studies reporting on bCS rates in COVID-19 patients and discuss why the reader should interpret the results of those reports with care. Moreover, we compare different national and international COVID-19 therapeutic guidelines from countries of the European Union. Specific attention is paid to guidance dedicated to rational antibiotic use. RESULTS: We found a significant heterogeneity in studies reporting on the epidemiology of bCSs in COVID-19 patients. Moreover, European national and international guidelines differ strongly from each other, especially with regard to the content and extent of antibiotic guidance in hospitalized COVID-19 patients. CONCLUSION: A standardized way of reporting on bCSs and uniform European guidelines on rational antibiotic use in COVID-19 patients are crucial for antimicrobial stewardship teams to halt unnecessary antibiotic use in the COVID-19 setting.

Coronavirus disease 2019 (COVID-19) associated bacterial coinfection: Incidence, diagnosis and treatment.

Coronavirus disease 2019 (COVID-19) emerged as a pandemic that spread rapidly around the world, causing nearly 500 billion infections and more than 6 million deaths to date. During the first wave of the pandemic, empirical antibiotics was prescribed in over 70% of hospitalized COVID-19 patients. However, research now shows a low incidence rate of bacterial coinfection in hospitalized COVID-19 patients, between 2.5% and 5.1%. The rate of secondary infections was 3.7% in overall, but can be as high as 41.9% in the intensive care units. Over-prescription of antibiotics to treat COVID-19 patients fueled the ongoing antimicrobial resistance globally. Diagnosis of bacterial coinfection is challenging due to indistinguishable clinical presentations with overlapping lower respiratory tract symptoms such as fever, cough and dyspnea. Other diagnostic methods include conventional culture, diagnostic syndromic testing, serology test and biomarkers. COVID-19 patients with bacterial coinfection or secondary infection have a higher in-hospital mortality and longer length of stay, timely and appropriate antibiotic use aided by accurate diagnosis is crucial to improve patient outcome and prevent antimicrobial resistance.

First Case of Splenic Abscess Parvimonas micra and Bacteremia Porphyromonas gingivalis Coinfection.

We report a case of a 76-year-old Caucasian male with bacteremia caused by Porphyromonas gingivalis and splenic abscess caused by Parvimonas micra. This patient presented with nonspecific symptoms: fever, chills, body aches, and shortness of breath. He was treated with IV piperacillin-tazobactam that was later switched to ampicillin sodium/sulbactam sodium during his hospital course and underwent a splenectomy. He ultimately expired due to acute respiratory failure and cardiac arrest, secondary to post-surgical complications. To our knowledge, this is the first case of P. micra and P. gingivalis coinfection.

When to Use Antibiotics in COVID-19: A Proposal Based on Questions.

The COVID-19 pandemic has affected millions of people, including hundreds of deaths. The search for adequate treatments and interventions that influence poor prognostic factors and reduce mortality has led to excessive use of antibiotics based on the possible existence of bacterial co-infection. However, there is no evidence to justify the systematic use of antimicrobials in COVID-19. The recommendations seek to provide knowledge regarding treatment; standardizing a management algorithm requires validation in clinical trials and studies of greater methodological rigor.

Bacterial coinfection and antimicrobial use among patients with COVID-19 infection in a referral center in the Philippines: A retrospective cohort study.

Objective: This study aimed to describe community-acquired bacterial coinfection (CAI) and antimicrobial use among COVID-19 patients. Methods: Electronic records were retrospectively reviewed, and clinical data, laboratory data, antibiotic use, and outcomes of patients with and without CAI were compared. Results: Of 1116 patients, 55.1% received antibiotics within 48 hours, but only 66 (5.9%) had documented CAI, mainly respiratory (40/66, 60.6%). Patients with CAI were more likely to present with myalgia (p = 0.02), nausea/vomiting (p = 0.014), altered sensorium (p = 0.007), have a qSOFA ≥ 2 (p = 0.016), or require vasopressor support (p < 0.0001). Patients with CAI also had higher median WBC count (10 vs 7.6 cells/mm3), and higher levels of procalcitonin (0.55 vs 0.13, p = 0.0003) and ferritin (872 vs 550, p = 0.028). Blood cultures were drawn for almost half of the patients (519, 46.5%) but were positive in only a few cases (30/519, 5.8%). Prescribing frequency was highest at the start and declined only slightly over time. The mortality of those with CAI (48.5%) was higher compared with those without CAI (14.3%). Conclusion: Overall CAI rate was low (5.9%) and antimicrobial use disproportionately high (55.0%), varying little over time. The mortality rate of coinfected patients was high. Certain parameters can be used to better identify those with CAI and those who need blood cultures.

Negative predictive value of procalcitonin to rule out bacterial respiratory co-infection in critical covid-19 patients.

BACKGROUND: Procalcitonin (PCT) and C-Reactive Protein (CRP) are useful biomarkers to differentiate bacterial from viral or fungal infections, although the association between them and co-infection or mortality in COVID-19 remains unclear. METHODS: The study represents a retrospective cohort study of patients admitted for COVID-19 pneumonia to 84 ICUs from ten countries between (March 2020-January 2021). Primary outcome was to determine whether PCT or CRP at admission could predict community-acquired bacterial respiratory co-infection (BC) and its added clinical value by determining the best discriminating cut-off values. Secondary outcome was to investigate its association with mortality. To evaluate the main outcome, a binary logistic regression was performed. The area under the curve evaluated diagnostic performance for BC prediction. RESULTS: 4635 patients were included, 7.6% fulfilled BC diagnosis. PCT (0.25[IQR 0.1-0.7] versus 0.20[IQR 0.1-0.5]ng/mL, p<0.001) and CRP (14.8[IQR 8.2-23.8] versus 13.3 [7-21.7]mg/dL, p=0.01) were higher in BC group. Neither PCT nor CRP were independently associated with BC and both had a poor ability to predict BC (AUC for PCT 0.56, for CRP 0.54). Baseline values of PCT<0.3ng/mL, could be helpful to rule out BC (negative predictive value 91.1%) and PCT≥0.50ng/mL was associated with ICU mortality (OR 1.5,p<0.001). CONCLUSIONS: These biomarkers at ICU admission led to a poor ability to predict BC among patients with COVID-19 pneumonia. Baseline values of PCT<0.3ng/mL may be useful to rule out BC, providing clinicians a valuable tool to guide antibiotic stewardship and allowing the unjustified overuse of antibiotics observed during the pandemic, additionally PCT≥0.50ng/mL might predict worsening outcomes.

Secondary Bacterial Infection and Clinical Characteristics in Patients With COVID-19 Admitted to Two Intensive Care Units of an Academic Hospital in Iran During the First Wave of the Pandemic.

Data on the prevalence of bacterial co-infections and secondary infection among adults with COVID-19 admitted to the intensive care unit (ICU) are rare. We aimed to determine the frequency of secondary bacterial infection, antibiotic use, and clinical characteristics in patients admitted to the ICU with severe SARS-CoV-2 pneumonia. This was a retrospective cohort study of adults with severe COVID-19 admitted to two ICUs from March 6 to September 7, 2020 in an academic medical center in Isfahan, Iran. To detect COVID-19, reverse transcription real-time polymerase chain reaction was performed and also typical pattern of CT scan was used for the diagnosis of COVID-19. Data collection included the age, gender, main symptoms, history of underlying disease, demographics, hospital stay, outcomes, and antibiotic regimen of the patient. Antimicrobial susceptibility testing was carried out according to the CLSI guidelines. During the study period, 553 patients were referred to the both ICUs for COVID-19 with severe pneumonia. Secondary bacterial infection was detected in 65 (11.9%) patients. The median age was 69.4 (range 21-95) years; 42 (63.6%) were men. Notably, 100% (n = 65) of the patients with superinfection were prescribed empirical antibiotics before first positive culture, predominantly meropenem (86.2%) with a median duration of 12 (range 2-32) days and levofloxacin (73.8%) with a median duration of nine (range 2-24) days. Most prevalent causative agents for secondary bacterial infection were Klebsiella pneumoniae (n = 44) and Acinetobacter baumannii (n = 33). Most patients with secondary bacterial infection showed extensive drug-resistance. The mortality among patients who acquired superinfections was 83% against an overall mortality of 38.1% in total admitted COVID-19 patients. We found a high prevalence of carbapenem-resistant Gram-negative bacilli in COVID-19 patients admitted to our ICUs, with a high proportion of K. pneumoniae followed by A. baumannii. These findings emphasize the importance of implementation of strict infection control measures and highlight the role of antimicrobial stewardship during a pandemic.

Opportunistic Infections in COVID-19: A Systematic Review and Meta-Analysis

The prevalence, incidence, and characteristics of bacterial infections in patients infected with severe acute respiratory syndrome coronavirus 2 are not well understood and have been raised as an important knowledge gap. Therefore, our study focused on the most common opportunistic infections/secondary infections/superinfections in coronavirus disease 2019 (COVID-19) patients.This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eligible studies were identified using PubMed/Medline since inception to June 25, 2021. Studies meeting the inclusion criteria were selected. Statistical analysis was conducted in Review Manager 5.4.1. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported as inverse variance and the corresponding 95% confidence interval.We screened 701 articles comprising 22 cohort studies which were included for analysis. The pooled prevalence of opportunistic infections/secondary infections/superinfections was 16% in COVID-19 patients. The highest prevalence of secondary infections was observed among viruses at 33%, followed by bacteria at 16%, fungi at 6%, and 25% among the miscellaneous group/wrong outcome.Opportunistic infections are more prevalent in critically ill patients. The isolated pathogens included Epstein-Barr virus, Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumannii, Hemophilus influenza, and invasive pulmonary aspergillosis. Large-scale studies are required to better identify opportunistic/secondary/superinfections in COVID-19 patients.