Abstract
Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilatorassociated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low. Objectives: We conducted an observational single-center study to determine the prevalence and etiology of bacterial superinfection at the time of initial intubation and the incidence and etiology of subsequent bacterial VAP in patients with severe SARS-CoV-2 pneumonia. Methods: Bronchoscopic BAL fluid samples fromall patients with SARS-CoV-2 pneumonia requiringmechanical ventilation were analyzed using quantitative cultures and amultiplex PCR panel. Actual antibiotic use was compared with guideline-recommended therapy. Measurements and Main Results: We analyzed 386 BAL samples from 179 patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. Bacterial superinfection within 48 hours of intubation was detected in 21% of patients. Seventy-two patients (44.4%) developed at least one VAP episode (VAP incidence rate = 45.2/1,000 ventilator days); 15 (20.8%) initial VAPs were caused by difficult-to-treat pathogens. The clinical criteria did not distinguish between patients with or without bacterial superinfection. BALbased management was associated with significantly reduced antibiotic use compared with guideline recommendations. Conclusions: In patients with SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection at the time of intubation occurs in <25% of patients. Guideline-based empirical antibiotic management at the time of intubation results in antibiotic overuse. Bacterial VAP developed in 44% of patients and could not be accurately identified in the absence of microbiologic analysis of BAL fluid.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 921-932 |
| Number of pages | 12 |
| Journal | American journal of respiratory and critical care medicine |
| Volume | 204 |
| Issue number | 8 |
| DOIs | |
| State | Published - Oct 15 2021 |
Funding
Signs, symptoms, and laboratory abnormalities in patients with SARS-CoV-2 pneumonia are identical to those of bacterial community-acquired pneumonia (CAP). Hence, most patients with severe SARS-CoV-2 pneumonia receive empirical antibiotic treatment to avoid undertreatment of superinfecting bacterial pathogens. This approach is supported by recommendations from the American Thoracic Society (ATS)/ Infectious Diseases Society of America (IDSA) CAP guidelines for documented viral pneumonia despite the acknowledged weak evidence for the recommendation (6). The World Health Organization and Surviving Sepsis guidelines specifically recommend empirical antibiotic treatment for severe SARS-CoV-2 pneumonia (7, 8). Later in the disease course, the persistence of fever, hypoxemia, radiographic infiltrates, and elevated inflammatory biomarkers over the unusually long duration of mechanical ventilation among patients with SARS-CoV-2pneumonia (9–18 d) (9–11) puts these patients at risk for both undertreatment of unrecognized VAP and overtreatment of clinically suspected VAP with empirical broad-spectrum antibiotic therapy (12). Supported by the NIH, National Institute of Allergy and Infectious Diseases (AI135964), NHLBI (HL128867, HL149883, HL147575, HL153122, and T32HL076139), National Institute on Aging (AG049665 and T32AG020506), U.S. National Library of Medicine (LM13337), NUCATS COVID-19 Rapid Response Grant, and CHEST Foundation.
Keywords
- Bronchoalveolar lavage
- COVID-19
- Community-acquired pneumonia
- Guideline therapy
- Ventilator-associated pneumonia
ASJC Scopus subject areas
- Pulmonary and Respiratory Medicine
- Critical Care and Intensive Care Medicine