The Effect of Nosocomial Infection on the Severity and Outcome of the Disease in Patients with Severe and Extremely Severe COVID-19

The mechanisms of development of nosocomial infectious complications in COVID-19 and the contribution of bacterial and mycotic superinfection to the formation of extremely high mortality among patients with severe and extremely severe course of this disease have not yet been fully revealed. The objective: to study epidemiology, risk factors for the development of nosocomial superinfection, and its effect on the severity and outcome of the disease in patients with COVID-19.
Subjects and Methods. 383 cases of severe and extremely severe COVID-19 were retrospectively analyzed. Demographic data, the presence of concomitant diseases, community-acquired co-infection at the time of hospitalization, data on the methods used to treat new coronavirus infection, severity of the course of the disease, developed infectious complications and their etiology, and the disease outcome were studied. Risk factors for the development of secondary infectious complications and the contribution of nosocomial superinfection to the severity of COVID-19 and the disease outcome were evaluated.
Results. Risk factors for the development of secondary infectious complications include age over 65 years (OR 1.04; 95% CI 1.03–1.06; p < 0.0001), concomitant cardiovascular pathology (OR 3.82; 95% CI 2.02‒7.19; p < 0.0001), chronic kidney disease, including requiring renal replacement therapy (OR 2.01; 95% CI 1.33–3.02; p = 0.0007), and glucocorticoid therapy (OR 1.62; 95% CI 1.02–2.69; p = 0.04). The development of nosocomial infectious complications in patients with COVID-19 is associated with a more severe course of the disease and unfavorable prognosis (OR 13.44; 95% CI 8.23‒21.92; p < 0.0001).
Conclusion. Identification of risk factors for the development of secondary infectious complications in COVID-19 allows developing differentiated approaches to the pathogenetic treatment of patients with severe COVID-19, increasing alertness in terms of the development of nosocomial infections, ensuring their timely diagnosis and treatment.

1. Bagnenko S.F., Polushin Yu.S., Shlyk I.V. et al. The Pavlov University experience in medical assistance for patients with the novel coronavirus infection: first results and lessons. Messenger of Anesthesiology and Resuscitation, 2021, vol. 18, no. 2, pp. 7-16. (In Russ.) https://doi.org/10.21292/2078-5658-2021-18-2-7-16.

2. Vremennye metodicheskie rekomendatsii. Profilaktika, diagnostika i lechenie novoy koronavirusnoy infektsii (COVID-19) Versiya 11. [Provisional guidelines on prevention, diagnostics and treatment of the new coronavirus infection (COVID-19). Version 11]. Approved by the Russian MoH as of May 7, 2021.

3. Kozlov V.А., Savchenko А.А., Kudryavtsev I.V. et al. Klinicheskaya immunologiya. [Clinical immunology]. Krasnoyarsk, Polikor Publ., 2020, 386 p. doi: 10.17513/np.438.

4. Bacterial infections in hospitalized COVID-19 patients – what we know so far. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Toronto, ON: Queen’s Printer for Ontario, 2020.

5. Clancy C., Schwartz I., Kula B., Nguyen M.H. Bacterial superinfections among persons with coronavirus disease 2019: A comprehensive review of data from postmortem studies. Open Forum Infect. Dis., vol. 8, iss. 3, March 2021. https://doi.org/10.1093/ofid/ofab065.

6. Coronavirus-Monitor.info © 2021 https://coronavirus-monitor.info.

7. Grasselli G., Scaravilli V., Mangioni D. et al. Hospital-acquired infections in critically ill patients with COVID-19. Chest, 2021, S0012-3692(21)00679-6. https://www.sciencedirect.com/science/article/pii/S0012369221006796?via%3Dihub.

8. Huang C., Wang Y., Li X., Ren L. et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 2020, vol. 395, iss. 10223, pp. 497–506. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159299/

9. Maes M., Higginson E., Pereira-Dias J. et al. Ventilator-associated pneumonia in critically ill patients with COVID-19. Crit. Care, 2021, vol. 25, Article number: 25. https://doi.org/10.1186/s13054-021-03460-5.

10. Mirzaei R., Goodarzi P., Asadi M. et al. Bacterial co-infections with SARS-CoV-2. Intern. Union Biochem. Molec. Biol., Aug. 2020, pp. 1–15. https://www.researchgate.net/publication/343534753_Bacterial_co-infections_with_SARS-CoV-2.

11. Moreno-Torres V., Mendoza C., Fuente S. at al. Bacterial infections in patients hospitalized with COVID-19. Intern. Emerg. Med., 2021 https://doi.org/10.1007/s11739-021-02824-7.

12. Nosheen N., Rehman F., Omair S.F. Risk factors for bacterial infections in patients with moderate to severe COVID-19: A case-control study. J. Med. Virol., 2021, no. 93, pp. 4564–4569. https://doi.org/10.1002/jmv.27000.

13. Obata R., Maeda T., Rizk D., Kuno T. Increased secondary infection in COVID-19 patients treated with steroids in new york city. Japan. J. Infect. Dis., 2021, vol. 74, iss. 4, pp. 307–315. https://doi.org/10.7883/yoken.JJID.2020.884.

14. Pettit N.N., Nguyen C.T., Mutlu G.M. et al. Late onset infectious complications and safety of tocilizumab in the management of COVID-19. J. Med. Virol., 2021, no. 93, pp. 1459‒1464. https://doi.org/10.1002/jmv.26429.

15. Pickens C., Gao C., Cuttica M. et al. Bacterial superinfection pneumonia in patients mechanically ventilated for COVID-19 pneumonia. Am. J. Respir. Crit. Care Med., vol. 204, iss. 8, pp. 921–932. https://www.atsjournals.org/doi/10.1164/rccm.202106-1354OC.

16. Vaillancourt M., Jorth P. The unrecognized threat of secondary bacterial infections with COVID-19. ASM Journals, mBio, 2020, vol. 11, no. 4. https://doi.org/10.1128/mBio.01806-20.