Patients with COVID-19 who are critically ill may be at increased risk for hospital-acquired infections (HAI), especially ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) caused by multidrug-resistant (MDR) bacteria, according to study findings published in Chest.

Few studies have characterized HAIs in patients with COVID-19. To address this knowledge gap, a team of investigators in Italy conducted a multicenter retrospective analysis ( Identifier: NCT04388670) of prospectively collected data to assess the characteristics and outcomes of patients hospitalized with severe COVID-19 who develop an HAI.

A total of 774 patients (median age, 62 years; 77% men) were included in the analysis. The median lengths of hospitalization and intensive care unit (ICU) stay were 29 days and 14 days, respectively. The median ratio of arterial oxygen partial pressure to fraction of inspired oxygen was 123 mm Hg, and 89% of patients required a median of 14 days of invasive mechanical ventilation (IMV). In addition, 9% of patients and 2.5% of patients underwent kidney replacement therapy and extracorporeal membrane oxygenation, respectively.

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Of the cohort, 359 patients (47%) developed a total of 759 HAIs (44.7 infections/1000 ICU patient-days), of which 35% were caused by MDR bacteria. The median number of days to first HAI was 12 days after hospital admission, 8 days after ICU admission, and 7 days after intubation. Of note, none of the patients admitted to the ICU who did not undergo IMV developed an HAI during their stay.

The most frequently observed HAIs were VAP (51%; 26.0/1000 intubation days), BSI (34%; 11.7/1000 ICU patient-days), and catheter-related BSI (10%; 4.7/1000 ICU patient-days). Of the VAP cases, 64% were caused by Gram-negative bacteria and 28% were caused by Staphylococcus aureus. The variables independently associated with infection were age, positive end expiratory pressure, and treatment with broad-spectrum antibiotics on hospital admission.

Of patients admitted to the ICU, 234 (30%) died during their stay (15.3 deaths/1000 ICU patient-days). Patients with HAIs complicated by septic shock had significantly increased mortality compared with those who did not develop an HAI (52% vs 29%, respectively); uncomplicated infections did not affect mortality rates.

Patients with infectious complications had significantly increased durations of IMV (median, 24 days vs 9 days; P <.001), ICU stay (median, 24 days vs 9 days; P =.003), and hospital stay (median, 42 days vs 23 days; P <.001).

“Patients with [HAIs] complicated by shock showed almost double mortality, and infected patients experienced prolonged [IMV] and hospitalization,” the investigators noted. “Clinicians should make every effort to implement protocols for surveillance and prevention of infectious complications,” they concluded.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original reference for a full list of disclosures.


Grasselli G, Scaravilli V, Mangioni D, et al. Hospital-acquired infections in critically ill patients with COVID-19. Chest. 2021;160(2):454-465. doi:10.1016/j.chest.2021.04.002