Bacterial Superinfections in Critically Ill Patients With SARS-CoV-2 Infection: A Retrospective Cohort Study

Background: There is a considerable gap in the current evidence concerning the prevalence of superinfections among critically ill patients with SARS-CoV-2 infection in Saudi Arabia. Objectives: We sought to determine the prevalence of bacterial superinfections following the initiation of antibiotic therapy in critically ill patients with SARS-CoV-2 infection. Methods: A retrospective observational study that included patients with SARS-CoV-2 infection admitted to the intensive care unit (ICU) for at least 24 hours and received empirical antibiotic therapy. The primary outcome was the rate of bacterial superinfections occurring at least 48 hours after the initiation of antibiotics. ICU-related outcomes and complications were compared between subgroups with and without superinfections and amongst the two most frequently used antibiotic regimens. Results: A total of 230 patients were included in our study. Superinfections developed in 40 (17.4%) patients, with the median time from the first dose of antibiotic to the emergence of superinfection of 17.6 days (IQR 9.8-29.2). Patients with superinfections had longer median ICU stays [ 27.1 days(IQR 15.2-43.3) versus 7.1 days(IQR 3.8-11.8); P < 0.001], developed more complications [92.5% versus 52.6%; P < 0.001], and had higher ICU mortality [45.0% versus 22.1%; P = 0.0034] compared to patients without superinfections. The two most frequently prescribed antibiotic regimens were piperacillin/tazobactam plus levofloxacin (53.9%) and meropenem plus levofloxacin (19.7%). Although there was no significant difference in the rate of superinfections [15.3% versus 26.7%; P = 0.09] between the two groups, patients in the superinfections group who received piperacillin/tazobactam plus levofloxacin developed more complications [94.7% versus 91.7%; P < 0.001] and had a higher ICU mortality [57.9% versus 50%; P < 0.001]. Conclusion: Superinfections occurred at a higher rate in critically ill patients with SARS-CoV-2 infection post empirical antibiotics initiation. The use of piperacillin/tazobactam plus levofloxacin was associated with an increase in the rate of complications and higher ICU mortality. Larger multicenter studies are needed to confirm these results.