The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients. This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson’s Chi-squared and continuous variables by Mann–Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the “full” matching method. Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO. In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021).

中文翻译：

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COIVD-19 ICU 患者的合并感染和 ICU 获得性感染：UNITE-COVID 数据集的二次分析

COVID-19 大流行给全球重症监护机构带来了重大挑战。在散发和大流行情况下，与病毒性肺炎同时发生或随后发生的感染是一个挑战；然而，数据表明，COVID-19 和其他病毒性肺炎的模式有所不同。这项二次分析旨在探讨合并感染和重症监护病房获得性感染 (ICU-AI) 的模式，以及在大型国际重症 COVID-19 患者队列中使用皮质类固醇的关系。这是一项多中心、国际观察性研究，包括在 COVID-19 第一波高峰期（2020 年 2 月 15 日至 5 月 15 日）入住 ICU 的经 PCR 确诊的 COVID-19 成年患者。收集的数据包括研究者评估的 ICU 入院时合并感染、ICU 内获得性感染、多重耐药菌 (MDRO) 感染和抗生素使用。频率通过皮尔逊卡方比较，连续变量通过曼-惠特尼 U 检验进行比较。使用 R 库 MatchIT 使用“完全”匹配方法对与 ICU 获得性感染相关的变量进行倾向评分匹配。数据来自 4994 名患者。716 名患者（14%）在入院时检测到细菌合并感染，同时 85% 的患者在该阶段接受了抗生素治疗。ICU-AI 发展于 2715 年（54%）。最常见的 ICU-AI 是细菌性肺炎（占感染的 44%），而 9% 的患者发展为真菌性肺炎；25% 的感染涉及 MDRO。在 ICU 中发生感染的患者比没有感染的患者有更多的抗菌药物暴露。事件密度（每 1000 个 ICU 天的 ICU-AI）远高于大流行前监测报告。ICU 之间皮质类固醇的使用情况存在差异。在单变量分析中，58% 接受皮质类固醇治疗的患者和 43% 未接受类固醇治疗的患者出现 ICU-AI。调整倾向匹配队列中的潜在混杂因素后，接受皮质类固醇治疗的患者中有 71% 发展为 ICU-AI，而未接受皮质类固醇治疗的患者这一比例为 52%。皮质类固醇治疗的持续时间也与 ICU-AI 的发展和 MDRO 感染有关。在第一波重症 COVID-19 患者中，入住 ICU 时合并感染的情况相对较少，但抗生素的使用远远超出了适应症。ICU-AI 很常见，并且与皮质类固醇的使用显着相关。试验注册 ClinicalTrials.gov：NCT04836065（于 2021 年 4 月 8 日追溯注册）。