Journal
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
Volume 204, Issue 8, Pages 921-932Publisher
AMER THORACIC SOC
DOI: 10.1164/rccm.202106-1354OC
Keywords
COVID-19; community-acquired pneumonia; ventilator-associated pneumonia; bronchoalveolar lavage; guideline therapy
Categories
Funding
- National Institute of Allergy and Infectious Diseases [AI135964]
- NHLBI [HL128867, HL149883, HL147575, HL153122, T32HL076139]
- National Institute on Aging [AG049665, T32AG020506]
- U.S. National Library of Medicine [LM13337]
- CHEST Foundation
- NUCATS COVID19 Rapid Response Grant
- NIH
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In patients with severe SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection occurs in 25% of patients at the time of intubation. Empirical antibiotic management based on guidelines leads to antibiotic overuse, while BAL-based management reduces antibiotic use significantly. VAP develops in 44% of patients and accurate identification relies on microbiologic analysis of BAL fluid.
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 ventilator-associated 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 from all patients with SARS-CoV-2 pneumonia requiring mechanical ventilation were analyzed using quantitative cultures and a multiplex 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. BAL-based 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.
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