Different epidemiology of bloodstream infections in COVID-19 compared to non-COVID-19 critically ill patients: a descriptive analysis of the Eurobact II study.

BACKGROUND: The study aimed to describe the epidemiology and outcomes of hospital-acquired bloodstream infections (HABSIs) between COVID-19 and non-COVID-19 critically ill patients. METHODS: We used data from the Eurobact II study, a prospective observational multicontinental cohort study on HABSI treated in ICU. For the current analysis, we selected centers that included both COVID-19 and non-COVID-19 critically ill patients. We performed descriptive statistics between COVID-19 and non-COVID-19 in terms of patients' characteristics, source of infection and microorganism distribution. We studied the association between COVID-19 status and mortality using multivariable fragility Cox models. RESULTS: A total of 53 centers from 19 countries over the 5 continents were eligible. Overall, 829 patients (median age 65 years [IQR 55; 74]; male, n = 538 [64.9%]) were treated for a HABSI. Included patients comprised 252 (30.4%) COVID-19 and 577 (69.6%) non-COVID-19 patients. The time interval between hospital admission and HABSI was similar between both groups. Respiratory sources (40.1 vs. 26.0%, p < 0.0001) and primary HABSI (25.4% vs. 17.2%, p = 0.006) were more frequent in COVID-19 patients. COVID-19 patients had more often enterococcal (20.5% vs. 9%) and Acinetobacter spp. (18.8% vs. 13.6%) HABSIs. Bacteremic COVID-19 patients had an increased mortality hazard ratio (HR) versus non-COVID-19 patients (HR 1.91, 95% CI 1.49-2.45). CONCLUSIONS: We showed that the epidemiology of HABSI differed between COVID-19 and non-COVID-19 patients. Enterococcal HABSI predominated in COVID-19 patients. COVID-19 patients with HABSI had elevated risk of mortality. Trial registration ClinicalTrials.org number NCT03937245 . Registered 3 May 2019.

Physical and psychological impairment in survivors of acute respiratory distress syndrome: a systematic review and meta-analysis.

BACKGROUND: Survivors of acute respiratory distress syndrome (ARDS) are at risk of long-term comorbidities. This systematic review and meta-analysis evaluated health-related quality of life (HRQoL), and physical and psychological impairments in ARDS survivors from 3 months to 5 yr follow-up after ICU discharge. METHODS: Systematic search of PubMed, AMED, BNI, and CINAHL databases from January 2000 to date. The primary outcome was HRQoL. Secondary outcomes included physical, pulmonary, and cognitive function, mental health, and return to work. A secondary analysis compared classical ARDS with severe acute respiratory syndrome coronavirus disease-2 (SARS-CoV-2) ARDS. RESULTS: Forty-eight papers met inclusion criteria including 11 693 patients; of those 85% (n=9992) had classical ARDS and 14% (n=1632) had SARS-CoV-2 ARDS. The 36-Item Short Form Health Survey (SF-36) physical component summary score mean (95% confidence interval [CI]) was 46 (41-50) at 3 months, 39 (36-41) at 6 months, and 40 (38-43) at 12 months. The SF-36 mental component summary mean score was 53 (48-57) at 3 months, 45 (40-50) at 6 months, and 44 (42-47) at 12 months. SF-36 values were lower than those found in the normal population up to 5 yr. The predictive distance walked in 6 min was 57% (45-69), 63% (56-69), and 66% (62-70) at 3, 6, and 12 months, respectively. Classical ARDS and SARS-CoV-2 ARDS showed no difference in HRQoL and physical function; however, patients with classical ARDS had higher incidence of anxiety and depression (P<0.001). CONCLUSION: ARDS survivors can experience reduced HRQoL and physical and mental health impairment. These symptoms might not recover completely up to 5 yr after ICU discharge. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021296506.

Development and early diagnosis of critical illness myopathy in COVID-19 associated acute respiratory distress syndrome.

BACKGROUND: The COVID-19 pandemic has greatly increased the incidence and clinical importance of critical illness myopathy (CIM), because it is one of the most common complications of modern intensive care medicine. Current diagnostic criteria only allow diagnosis of CIM at an advanced stage, so that patients are at risk of being overlooked, especially in early stages. To determine the frequency of CIM and to assess a recently proposed tool for early diagnosis, we have followed a cohort of COVID-19 patients with acute respiratory distress syndrome and compared the time course of muscle excitability measurements with the definite diagnosis of CIM. METHODS: Adult COVID-19 patients admitted to the Intensive Care Unit of the University Hospital Bern, Switzerland requiring mechanical ventilation were recruited and examined on Days 1, 2, 5, and 10 post-intubation. Clinical examination, muscle excitability measurements, medication record, and laboratory analyses were performed on all study visits, and additionally nerve conduction studies, electromyography and muscle biopsy on Day 10. Muscle excitability data were compared with a cohort of 31 age-matched healthy subjects. Diagnosis of definite CIM was made according to the current guidelines and was based on patient history, results of clinical and electrophysiological examinations as well as muscle biopsy. RESULTS: Complete data were available in 31 out of 44 recruited patients (mean [SD] age, 62.4 [9.8] years). Of these, 17 (55%) developed CIM. Muscle excitability measurements on Day 10 discriminated between patients who developed CIM and those who did not, with a diagnostic precision of 90% (AUC 0.908; 95% CI 0.799-1.000; sensitivity 1.000; specificity 0.714). On Days 1 and 2, muscle excitability parameters also discriminated between the two groups with 73% (AUC 0.734; 95% CI 0.550-0.919; sensitivity 0.562; specificity 0.857) and 82% (AUC 0.820; CI 0.652-0.903; sensitivity 0.750; specificity 0.923) diagnostic precision, respectively. All critically ill COVID-19 patients showed signs of muscle membrane depolarization compared with healthy subjects, but in patients who developed CIM muscle membrane depolarization on Days 1, 2 and 10 was more pronounced than in patients who did not develop CIM. CONCLUSIONS: This study reports a 55% prevalence of definite CIM in critically ill COVID-19 patients. Furthermore, the results confirm that muscle excitability measurements may serve as an alternative method for CIM diagnosis and support its use as a tool for early diagnosis and monitoring the development of CIM.

Rehabilitation Characteristics of Acute-stage COVID-19 Survivors Managed with Extracorporeal Membrane Oxygenation in the Intensive Care Unit.

Objectives: This study aimed to describe the rehabilitation characteristics of patients with acute stage coronavirus disease managed with extracorporeal membrane oxygenation (ECMO) in the intensive care unit. Methods: This retrospective study enrolled coronavirus disease patients who underwent rehabilitation following ECMO between April 21, 2020, and August 20, 2021. The following patient data were evaluated: age, sex, weaning, peak C-reactive protein, lowest albumin level, white blood cell count, use of steroids and muscle relaxants, duration of respiratory management, ECMO management and rehabilitation, Medical Research Council (MRC) score, and Barthel index after sedation and at discharge. Results: ECMO was performed in 20 patients, and 16 were weaned successfully. The median durations of ECMO and respiratory management in survivors were 14.5 and 38 days, respectively. The median MRC scores after sedation and after rehabilitation therapy were 18 and 45, respectively. The median rehabilitation duration after sedation was 14 days. The MRC score after sedation showed significant correlations with the durations of ECMO and intubation. The median Barthel index values after sedation and at discharge were 0 and 30, respectively. Conclusions: Rehabilitation was important for patients with severe coronavirus disease because muscle weakness advanced in proportion with the durations of ECMO and ventilation management in the intensive care unit.

Antimicrobial prescription in severe COVID-19 and CAP: a matched case-control study.

BACKGROUND: In severe coronavirus diseases 2019 (COVID-19), a high and potentially excessive use of antimicrobials for suspected bacterial co-infection and intensive care unit (ICU)-acquired infections has been repeatedly reported. OBJECTIVES: To compare an ICU cohort of community-acquired pneumonia (CAP) with a cohort of severe COVID-19 pertaining to co-infections, ICU-acquired infections and associated antimicrobial consumption. METHODS: We retrospectively compared a cohort of CAP patients with a cohort of COVID-19 patients matched according to organ failure, ICU length of stay (LOS) and ventilation days. Patient data such as demographics, infection focus, probability and severity, ICU severity scores and ICU and in-hospital mortality, days of antimicrobial therapy (DOT) and number of antimicrobial prescriptions, using an incremental scale, were registered and analysed. The total number of cultures (sputum, urinary, blood cultures) was collected and corrected for ICU LOS. FINDINGS: CAP patients (n = 148) were matched to COVID-19 patients (n = 74). Significantly less sputum cultures (68.2% versus 18.9%, P < 0.05) and bronchoalveolar lavages (BAL) (73.7% versus 36.5%, P < 0.05) were performed in COVID-19 patients. Six (8.1%) COVID-19 patients were diagnosed with a co-infection. Respectively, 58 of 148 (39.2%) CAP and 38 of 74 (51.4%) COVID-19 patients (P = 0.09) developed ICU-acquired infections. Antimicrobial distribution, both in the number of prescriptions and DOT, was similar in both cohorts. CONCLUSIONS: We found a low rate of microbiologically confirmed bacterial co-infection and a high rate of ICU-acquired infections in COVID-19 patients. Infection probabilities, antimicrobial prescriptions and DOT were comparable with a matched CAP cohort.

Physical recovery of COVID-19 pneumosepsis intensive care survivors compared with non-COVID pneumosepsis intensive care survivors during post-intensive care hospitalization: The RECOVID retrospective cohort study.

BACKGROUND: Coronavirusdisease 2019 (COVID-19) pneumosepsis survivors are at a high risk of developing intensive care unit (ICU)-acquired weakness (ICUAW) because of high incidence of acute respiratory distress syndrome and the common need for prolonged invasive ventilation. It remains unknown whether regular postpneumosepsis physical rehabilitation strategies are suitable for this extraordinary patient category. METHODS: We retrospectively compared the physical recovery of COVID-19 and non-COVID pneumosepsis ICU survivors during post-ICU hospitalization, defined as the difference in performance on the Medical Research Council Sum-Score (MRC-SS), Chelsea Critical Care Physical Assessment tool (CPAx), and percentage of predicted handgrip strength (POP-HGS). An analysis of covariance model was built using age, sex, Barthel index, body mass index, admission Acute Physiology And Chronic Health Evaluation II score, adequacy of protein delivery during ICU stay, and ward length of stay as covariates. RESULTS: Thirty-five COVID-19 ICU patients could be compared with 21 non-COVID pneumosepsis ICU survivors. All patients scored ≤48 on the MRC-SS at ICU discharge, indicating ICUAW. When controlling for covariates, COVID-19 patients performed worse on all physical assessments upon ICU discharge, but had improved more at hospital discharge on the MRC-SS (ɳ2 = 0.214, P =.002) and CPAx (ɳ2 = 0.153, P =.011). POP-HGS remained lower in COVID-19 patients throughout hospital stay. CONCLUSION: COVID-19 ICU survivors are vulnerable to ICUAW, but they show better tendency towards physical rehabilitation than non-COVID pneumosepsis ICU survivors during the post-ICU hospitalization period regarding MRC-SS and CPAx. COVID-19 ICU patients might benefit from early, more intensive physical therapy.

Critical illness myopathy after COVID-19.

This paper describes a patient who developed diffuse and symmetrical muscle weakness after a long stay in the intensive care unit (ICU) due to coronavirus disease 2019 (COVID-19). The patient underwent a neurophysiological protocol, including nerve conduction studies, concentric needle electromyography (EMG) of the proximal and distal muscles, and direct muscle stimulation (DMS). Nerve conduction studies showed normal sensory conduction and low-amplitude compound muscle action potentials (CMAPs). EMG revealed signs of myopathy, which were more pronounced in the lower limbs. The post-DMS CMAP was absent in the quadriceps and of reduced amplitude in the tibialis anterior muscle. Based on these clinical and neurophysiological findings, a diagnosis of critical illness myopathy was made according to the current diagnostic criteria. Given the large number of patients with COVID-19 who require long ICU stays, many are very likely to develop ICU-acquired weakness, as did the patient described here. Health systems must plan to provide adequate access to rehabilitative facilities for both pulmonary and motor rehabilitative treatment after COVID-19.