A Study on Secondary Infections in Patients with COVID-19 Admitted to ICU

ABSTRACT

Introduction: COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has resulted in 119.2 million infections and 2.64 million deaths by 14 March 2021, globally. As of March 14, 2021, India has seen 11.35 million infections and 0.15 million deaths. Critically ill COVID-19 patients need hospitalization, which increases their risk of acquiring secondary bacterial and fungal infections and would lead to a significant increase in morbidity and mortality. The prevalence of secondary infections in ICU patients infected with COVID-19 is not well understood. Objectives: The aim of our study was to know the prevalence and impact of secondary infections on patients with COVID-19 infection admitted to ICU. Materials and methods: This was an observational prospective study conducted in Apollo hospital, for a period of 6 months (December 2020 to June 2021). We considered patients who develop secondary infections (bacterial/ fungal) developed 48 hours after ICU admission until death or discharge. Results: Among 50 patients, males were 68% and females were 32%. The mean age at presentation was 55 years. Secondary infections were detected in 29 patients (58%) with a median of 9 days after intensive care unit (ICU) admission (Fig. 1). Among which 79.3% was bacterial and 20.7% was fungal infections. Most of which were isolated from blood-16/29 patients (55.2%), respiratory-9/29 patients (31.03%), and urine-4/29 patients (13.8%). Gram-negative organisms were predominant [Klebsiella (39.1%), Acinetobacter (26.1%), E. coli (17.4%), Pseudomonas (13.0%)] over grampositive organisms-enterococci (4.4%). Among fungal infections, Aspergillosis in 3/6 patients (50%), Mucor in 1/6 patients (16.7%), and Candida in 2/6 patients (33.3%) were noted. The average length of ICU stay in patients with secondary infections was significantly high when compared to patients without secondary infections. Out of 50 patients, 10 patients were on high oxygen support, 24 required BIPAP support, 16 were ventilated. Patients who developed secondary infections received a high dose of steroids (mean dose of steroids received was 1996 mg). Patients receiving invasive mechanical ventilation or longer ICU (>9 days) stay had a higher rate of secondary infections (p < 0.001). Similarly, a 28-day mortality rate was also more in patients with secondary infections (17/29 patients;58.62%) when compared to patients without infections (5/21 patients;23.8%). Conclusion: For critically ill COVID patients, the secondary infection rates were found to be high. Although antibiotics likely provide minimal benefit as empirical treatment in COVID-19 patients and may be associated with unintended consequences including adverse events, toxicity, resistance, and C. difficile infections, it is always prudent for clinicians to prescribe them judiciously to ICU patients to reduce the length of ICU stay and mortality. We must have a high suspicion for fungal infections in patients who have long ICU stays and not improving with empirical antibiotics, as early detection and timely treatment may reduce mortality (Figs 2-4).