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Bacterial Superinfections Among Persons With Coronavirus Disease 2019: A Comprehensive Review of Data From Postmortem
Cornelius J Clancy1, Ilan S Schwartz2, Brittany Kula2
1Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Background:
Limited clinical data suggest a ~16% prevalence of bacterial superinfections among critically ill patients with coronavirus disease 2019 (COVID-19).
Methods:
We reviewed postmortem studies of patients with COVID-19 published in English through September 26, 2020, for histopathologic findings consistent with bacterial lung infections.
Results:
Worldwide, 621 patients from 75 studies were included. The quality of data was uneven, likely because identifying superinfections was not a major objective in 96% (72/75) of studies. Histopathology consistent with a potential lung superinfection was reported in 32% (200/621) of patients (22-96 years old; 66% men). Types of infections were pneumonia (95%), abscesses or empyema (3.5%), and septic emboli (1.5%). Seventy-three percent of pneumonias were focal rather than diffuse. The predominant histopathologic findings were intra-alveolar neutrophilic infiltrations that were distinct from those typical of COVID-19-associated diffuse alveolar damage. In studies with available data, 79% of patients received antimicrobial treatment; the most common agents were beta-lactam/beta-lactamase inhibitors (48%), macrolides (16%), cephalosoprins (12%), and carbapenems (6%). Superinfections were proven by direct visualization or recovery of bacteria in 25.5% (51/200) of potential cases and 8% of all patients in postmortem studies. In rank order, pathogens included Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Lung superinfections were the cause of death in 16% of potential cases and 3% of all patients with COVID-19.
Conclusions:
Potential bacterial lung superinfections were evident at postmortem examination in 32% of persons who died with COVID-19 (proven, 8%; possible, 24%), but they were uncommonly the cause of death.
Insights
Bacterial lung superinfections were found in 32% of COVID-19 deaths, with 8% confirmed. These infections were rarely the primary cause of death in critically ill patients.
Area of Science:
- Infectious Diseases
- Pulmonology
- Critical Care Medicine
Background:
- Limited clinical data indicate a bacterial superinfection prevalence of approximately 16% in critically ill coronavirus disease 2019 (COVID-19) patients.
- Bacterial lung superinfections represent a significant, yet understudied, complication in COVID-19 mortality.
Purpose of the Study:
- To investigate the prevalence and characteristics of bacterial lung superinfections in patients who died from COVID-19 using postmortem histopathology.
- To identify common pathogens and assess the contribution of superinfections to mortality in COVID-19 cases.
Main Methods:
- A systematic review of postmortem studies on COVID-19 patients published in English up to September 26, 2020.
- Analysis of histopathologic findings for evidence of bacterial lung infections, including pneumonia, abscesses, empyema, and septic emboli.
- Categorization of superinfections as potential or proven based on direct visualization or bacterial recovery.
Main Results:
- Histopathology suggested bacterial lung superinfection in 32% (200/621) of deceased COVID-19 patients across 75 studies.
- Pneumonia was the most common type (95%), with distinct intra-alveolar neutrophilic infiltrations.
- Proven bacterial superinfections were identified in 8% of all patients, with common pathogens including Acinetobacter baumannii and Staphylococcus aureus.
- Bacterial superinfections were the cause of death in 3% of all patients and 16% of those with potential superinfections.
Conclusions:
- Postmortem examination revealed potential bacterial lung superinfections in 32% of COVID-19 deaths (8% proven, 24% possible).
- While prevalent, bacterial lung superinfections were infrequently the direct cause of mortality in this cohort.
- Findings highlight the importance of considering bacterial superinfections in COVID-19 management and autopsy protocols.
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