key: cord-0733284-o87q3qfd
authors: Gil, Eliza; Martyn, Emily; Rokadiya, Sakib; Jain, Sarjana; Chin, Teh Li
title: Bacterial Coinfection in COVID-19
date: 2020-08-06
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1120
sha: ab06cabe96ed7704db4e5a40cc2290bc01e4c844
doc_id: 733284
cord_uid: o87q3qfd

nan

To the Editor-We read with interest the work of Rawson et al, "Bacterial and Fungal Coinfection in Individuals With Coronavirus: A Rapid Review to Support COVID-19 Antimicrobial Prescribing" [1] . In most of the cited studies there is no distinction made on the timing of acquisition of the infection relative to the patients' coronavirus disease 2019 (COVID-19) diagnosis. This results in the inclusion of both coinfections: 2 separate infectious processes contemporaneously and secondary infections; and a second infective process developing as a result of the first. In fact, almost all studies considered by Rawson et al examine infections secondary to COVID-19.

The North Middlesex University Hospital (NMUH) was one of the most COVID-19 affected hospitals in the early stages of the pandemic in the United Kingdom [2] . At this time the prevalence of COVID-19 among the community served by NMUH was high: from 1 March 2020 to 30 April 2020, 728 of the 1944 (37%) patients tested by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) returned positive results. This study examined the incidence of diagnosis at presentation of both COVID-19 and a confirmed bacterial bloodstream coinfection.

From 1 March 2020 to 30 April 2020, 420 patients were identified as SARS-CoV-2 PCR positive on nasopharyngeal swab at the time of admission to NMUH. Eleven (3%) also had a significant positive blood culture (excluding the growth of skin flora organisms in a single set of blood cultures). These patients were older (median 83 years, interquartile range [IQR] 71-86) than the cohort of admitted COVID-19 patients as a whole (median 64, IQR 50-79). All had ≥1 comorbidity that has been identified as a risk factor for severe COVID-19 disease [3] (Table 1 ). The range of clinical presentations, organisms identified, and underlying causative pathologies were diverse (Table 1) . Only 2/11 (18%) patients reported respiratory symptoms, and 4/11 (36%) reported fever. Although the prevalence of respiratory symptoms was low, 6/11 (55%) had a chest radiograph consistent with COVID-19 infection at the time of presentation. Despite the universal treatment of severely unwell emergency department patients with ceftriaxone at this time, the outcomes of patients with COVID-19 and bacteremia were poor: 7/11 (64%) patients died during their admission, and the remaining 4 (36%) had prolonged hospital admissions (8-17 days, median 14 days).

The majority, if not all, of these cases represented true bacterial coinfection of an etiology independent of COVID-19 (Table 1 ). This suggests that in times of high COVID-19 prevalence Hickam's dictum, "a patient may have as many diseases as he pleases, " trumps Occam's razor, the principle that a single explanation for the patient's symptoms is most likely, particularly in older patients. Rawson et al rightly identify the need for antibiotic stewardship in the era of COVID-19, especially given low rates of confirmed bacterial infection [1] . However, the nonspecific presentation of COVID-19 patients with bacterial coinfection makes them challenging to identify prospectively, and their outcomes are extremely poor. In the context of increasing availability of rapid SARS-CoV-2 testing, it is imperative that clinicians remain alert to the possibility of bacterial coinfection and that patients are not denied antibiotics based on a positive SARS-CoV-2 result in the emergency department.

Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing

Revealed: the hospitals facing most pressure to meet coronavirus demand

Clinical course and risk factors for mortality of adult in patients with COVID-19 in Wuhan, China: a retrospective cohort study