Secondary infections modify the overall course of hospitalized COVID-19 patients: A retrospective study from a network of hospitals across North India
Authors: Budhiraja Sandeep , Tarai Bansidhar , Jain Dinesh , Aggarwal Mona , Indrayan Abhaya , Das Poonam , Mishra RS , Bali Supriya , Mahajan Monica , Kirtani Jay , Tickoo Rommel , Soni Pankaj , Nangia Vivek , Lall Ajay , Kishore Nevin , Jain Ashish , Singh Omender , Singh Namrita , Kumar Ashok , Saxena Prashant , Dewan Arun , Aggarwal Ritesh , Mehra Mukesh , Jain Meenakshi , Nakra Vimal , Sharma B D , Pandey Praveen Kumar , Singh YP , Arora Vijay , Jain Suchitra , Chhabra Ranjana , Tuli Preeti , Boobna Vandana , Joshi Alok , Aggarwal Manoj , Gupta Rajiv , Aneja Pankaj , Dhall Sanjay , Arora Vineet , Chugh Inder Mohan , Garg Sandeep , Mittal Vikas , Gupta Ajay , Jyoti Bikram , Sharma Puneet , Bhasin Pooja , Jain Shakti , Singhal RK , Bhasin Atul , Vardani Anil , Pal Vivek , Pande Deepak Gargi , Gulati Tribhuvan , Nayar Sandeep , Kalra Sunny , Garg Manish , Pande Rajesh , Bag Pradyut , Gupta Arpit , Sharma Jitin , Handoo Anil , Burman Purabi , Gupta Ajay Kumar , Choudhary Pankaj Nand , Gupta Ashish , Gupta Puneet , Joshi Sharad , Tayal Nitesh , Gupta Manish , Khanna Anita , Kishore Sachin , Sahay Shailesh , Dang Rajiv , Mishra Neelima , Sekhri Sunil , Srivastava Rajneesh Chandra , Agrawal Mitali Bharat , Mathur Mohit , Banwari Akash , Khetarpal Sumit , Pandove Sachin , Bhasin Deepak , Singh Harpal , Midha Devender , Bhutani Anjali , Kaur Manpreet , Singh Amarjit , Sharma Shalini , Singla Komal , Gupta Pooja , Sagar Vinay , Dixit Ambrish , Bajpai Rashmi , Chachra Vaibhav , Tyagi Puneet , Saxena Sanjay , Uniyal Bhupesh , Belwal Shantanu , Aier Imliwati , Singhal Mini , Khaduri Ankit 
Published: September 2021

Introduction

SARS-CoV-2 infection increases the risk of secondary bacterial and fungal infections and contributes to adverse outcomes. The present study was undertaken to get better insights into the extent of secondary bacterial and fungal infections in Indian hospitalized patients and to assess how these alter the course of COVID-19 so that the control measures can be suggested.

Methods

This is a retrospective, multicentre study where data of all RT-PCR positive COVID-19 patients was accessed from Electronic Health Records (EHR) of a network of 10 hospitals across 5 North Indian states, admitted during the period from March 2020 to July 2021.The data included demographic profile of patients, clinical characteristics, laboratory parameters, treatment modalities, and outcome in those with secondary infections (SIs) and those without SIs. Spectrum of SIS was also studied in detail.

Results

Of 19852 RT-PCR positive SARS-CO2 patients admitted during the study period, 1940 (9.8%) patients developed SIs. Patients with SIs were 8 years older on average (median age 62.6 years versus 54.3 years; P<0.001) than those without SIs. The risk of SIs was significantly (p < 0.001) associated with age, severity of disease at admission, diabetes, ICU admission, and ventilator use.

The most common site of infection was urinary tract infection (UTI) (41.7%), followed by blood stream infection (BSI) (30.8%), sputum/BAL/ET fluid (24.8%), and the least was pus/wound discharge (2.6%). As many as 13.4% had infections with more than organism and 34.1% patients had positive cultures from more than one site. Gram negative bacilli (GNB) were the commonest organisms (63.2%), followed by Gram positive cocci (GPC) (19.6%) and fungus (17.3%). Most of the patients with SIs were on multiple antimicrobials – the most commonly used were the BL-BLI for GNBs (76.9%) followed by carbapenems (57.7%), cephalosporins (53.9%) and antibiotics carbapenem resistant entreobacteriace (47.1%). The usage of emperical antibiotics for GPCs was in 58.9% and of antifungals in 56.9% of cases, and substantially more than the results obtained by culture.

The average stay in hospital for patients with SIs was twice than those without SIs (median 13 days versus 7 days). The overall mortality in the group with SIs (40.3%) was more than 8 times of that in those without SIs (4.6%). Only 1.2% of SI patients with mild COVID-19 at presentation died, while 17.5% of those with moderate disease and 58.5% of those with severe COVID-19 died (P< 0.001). The mortality was highest in those with BSI (49.8%), closely followed by those with HAP (47.9%), and then UTI and SSTI (29.4% each). The mortality rate where only one microorganism was identified was 37.8% and rose to 56.3% in those with more than one microorganism. The mortality in cases with only one site of infection was 28.8%, which steeply rose to 62.5% in cases with multiple sites of infection. The mortality in diabetic patients with SIs was 45.2% while in non-diabetics it was 34.3% (p < 0.001).

Conclusions

Secondary bacterial and fungal infections can complicate the course of almost 10% of COVID-19 hospitalised patients. These patients tend to not only have a much longer stay in hospital, but also a higher requirement for oxygen and ICU care. The mortality in this group rises steeply by as much as 8 times. The group most vulnerable to this complication are those with more severe COVID-19 illness, elderly, and diabetic patients. Varying results in different studies suggest that a region or country specific guideline be developed for appropriate use of antibiotics and antifungals to prevent their overuse in such cases. Judicious empiric use of combination antimicrobials in this set of vulnerable COVID-19 patients can save lives.