Co-infection in critically ill patients with COVID-19: An observational cohort study from England

Objective To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England. Methods A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 hours following hospital admission, corresponding to community and hospital-acquired co-infections. Results Of 254 patients studied (median age 59 years (IQR 49-69); 64.6% male), 139 clinically significant organisms were identified from 83(32.7%) patients. Bacterial co-infections were identified within 48 hours of admission in 14(5.5%) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli . The co-infection rate >48 hours after admission was 27/1000 person-days (95% CI 21.3-34.1). Patients with co-infections were more likely to die in ICU (crude OR 1.78,95% CI 1.03-3.08, p=0.04) compared to those without co-infections. Conclusion We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay. ### Competing Interest Statement Professor Lim reports grants from National Institute for Health Research (NIHR), grants from Pfizer, outside the submitted work. Paul Dark is funded by NIHR Manchester BRC as sub-theme lead in Respiratory Infections. ### Funding Statement This research was funded by the NIHR Nottingham Biomedical Research Centre. The views expressed are those of the author(s). The funders had no role in the design, analysis or write up of this manuscript. Grant number: BRC-1215-20003. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was given by HRA and REC; protocol number:20RM040, IRAS project ID:284341. Section 251 support from the Confidentiality Advisory Committee for use of anonymised NHS patient data was not required according to the temporary General Notice issued for COVID-19 purposes by the Secretary of State for Health and Social Care under the Health Service Control of Patient Information Regulations 2002. All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes Data are available from the corresponding author on reasonable request.