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Pulmonary Co-Infections Detected Premortem Underestimate Postmortem Findings in a COVID-19 Autopsy Case Series
Andrew P Platt1,2, Benjamin T Bradley3, Nadia Nasir4
1Emerging Pathogens Section, Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA.
Abstract:
Bacterial and fungal co-infections are reported complications of coronavirus disease 2019 (COVID-19) in critically ill patients but may go unrecognized premortem due to diagnostic limitations. We compared the premortem with the postmortem detection of pulmonary co-infections in 55 fatal COVID-19 cases from March 2020 to March 2021. The concordance in the premortem versus the postmortem diagnoses and the pathogen identification were evaluated. Premortem pulmonary co-infections were extracted from medical charts while applying standard diagnostic definitions. Postmortem co-infection was defined by compatible lung histopathology with or without the detection of an organism in tissue by bacterial or fungal staining, or polymerase chain reaction (PCR) with broad-range bacterial and fungal primers. Pulmonary co-infection was detected premortem in significantly fewer cases (15/55, 27%) than were detected postmortem (36/55, 65%; p < 0.0001). Among cases in which co-infection was detected postmortem by histopathology, an organism was identified in 27/36 (75%) of cases. Pseudomonas, Enterobacterales, and Staphylococcus aureus were the most frequently identified bacteria both premortem and postmortem. Invasive pulmonary fungal infection was detected in five cases postmortem, but in no cases premortem. According to the univariate analyses, the patients with undiagnosed pulmonary co-infection had significantly shorter hospital (p = 0.0012) and intensive care unit (p = 0.0006) stays and significantly fewer extra-pulmonary infections (p = 0.0021). Bacterial and fungal pulmonary co-infection are under-recognized complications in critically ill patients with COVID-19.
Insights
Pulmonary co-infections in critically ill COVID-19 patients are often missed before death. Postmortem analysis revealed significantly more bacterial and fungal infections than clinical diagnoses, highlighting under-recognition of these serious complications.
Area of Science:
- Infectious Diseases
- Pulmonology
- Critical Care Medicine
Background:
- Bacterial and fungal co-infections are known complications of severe coronavirus disease 2019 (COVID-19).
- Premortem diagnosis of pulmonary co-infections can be limited in critically ill patients.
- Under-recognition of these co-infections may impact patient outcomes.
Purpose of the Study:
- To compare premortem clinical diagnoses with postmortem findings of pulmonary co-infections in fatal COVID-19 cases.
- To evaluate the concordance of pathogen identification between premortem and postmortem analyses.
- To determine the prevalence and types of bacterial and fungal co-infections in COVID-19 fatalities.
Main Methods:
- Retrospective analysis of 55 fatal COVID-19 cases from March 2020 to March 2021.
- Premortem co-infections identified from medical charts using standard definitions.
- Postmortem co-infections diagnosed via lung histopathology, microbial staining, and broad-range PCR for bacteria and fungi.
Main Results:
- Pulmonary co-infections were detected in significantly fewer cases premortem (27%) compared to postmortem (65%).
- Organisms were identified in 75% of postmortem cases with diagnosed co-infection.
- Common bacteria included *Pseudomonas*, *Enterobacterales*, and *Staphylococcus aureus*; invasive fungal infections were found postmortem but not premortem.
- Undiagnosed co-infections were associated with shorter hospital and ICU stays.
Conclusions:
- Bacterial and fungal pulmonary co-infections are significantly under-recognized in critically ill COVID-19 patients.
- Postmortem examination reveals a higher burden of co-infections than typically diagnosed clinically.
- Improved diagnostic strategies are needed to identify and manage these complications during critical illness.
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