Ventilator-associated pneumonia in patients with SARS-CoV-2-associated acute respiratory distress syndrome requiring ECMO: a retrospective cohort study

Charles-Edouard Luyt (1, 2, 3) , Tarek Sahnoun (1, 2, 3) , Melchior Gautier (1, 2, 3) , Pauline Vidal (3) , Sonia Burrel (3, 4) , Marc Pineton de Chambrun (1, 2, 3) , Juliette Chommeloux (1, 2, 3) , Cyrielle Desnos (1, 2, 3) , Jeremy Arzoine (3) , Ania Nieszkowska (1, 2, 3) , Nicolas Bréchot (1, 2, 3) , Matthieu Schmidt (1, 2, 3) , Guillaume Hekimian (1, 2, 3) , David Boutolleau (3, 4) , Jérôme Robert (3) , Alain Combes (1, 2, 3) , Jean Chastre (1, 2, 3)

1 ICAN - Unité de Recherche sur les Maladies Cardiovasculaires, du Métabolisme et de la Nutrition = Research Unit on Cardiovascular and Metabolic Diseases
2 Institut de cardiologie [CHU Pitié-Salpêtrière]
3 CHU Pitié-Salpêtrière [AP-HP]
4 iPLESP - Institut Pierre Louis d'Epidémiologie et de Santé Publique

Background: The data on incidence, clinical presentation, and outcomes of ventilator-associated pneumonia (VAP) in patients with severe coronavirus disease 2019 (COVID-19) pneumonia requiring mechanical ventilation (MV) are limited. We performed this retrospective cohort study to assess frequency, clinical characteristics, responsible pathogens, and outcomes of VAP in patients COVID-19 pneumonia requiring MV between March 12th and April 24th, 2020 (all had RT-PCR-confirmed SARS-CoV-2 infection). Patients with COVID-19-associated acute respiratory distress syndrome (ARDS) requiring ECMO were compared with an historical cohort of 45 patients with severe influenza-associated ARDS requiring ECMO admitted to the same ICU during the preceding three winter seasons. Results: Among 50 consecutive patients with Covid-19-associated ARDS requiring ECMO included [median (IQR) age 48 (42-56) years; 72% male], 43 (86%) developed VAP [median (IQR) MV duration before the first episode, 10 (8-16) days]. VAP-causative pathogens were predominantly Enterobacteriaceae (70%), particularly inducible AmpC-cephalosporinase producers (40%), followed by Pseudomonas aeruginosa (37%). VAP recurred in 34 (79%) patients and 17 (34%) died. Most recurrences were relapses (i.e., infection with the same pathogen), with a high percentage occurring on adequate antimicrobial treatment. Estimated cumulative incidence of VAP, taking into account death and extubation as competing events, was significantly higher in Covid-19 patients than in influenza patients (p = 0.002). Despite a high P. aeruginosa-VAP rate in patients with influenza-associated ARDS (54%), the pulmonary infection recurrence rate was significantly lower than in Covid-19 patients. Overall mortality was similar for the two groups. Conclusions: Patients with severe Covid-19-associated ARDS requiring ECMO had a very high late-onset VAP rate. Inducible AmpC-cephalosporinase-producing Enterobacteriaceae and Pseudomonas aeruginosa frequently caused VAP, with multiple recurrences and difficulties eradicating the pathogen from the lung.

Mots clés: Ventilator-associated pneumonia; Coronavirus; Covid-19; Enterobacteriaceae; ECMO; ARDS

Domaines: Sciences du Vivant [q-bio]

Charles-Edouard Luyt, Tarek Sahnoun, Melchior Gautier, Pauline Vidal, Sonia Burrel, et al.. Ventilator-associated pneumonia in patients with SARS-CoV-2-associated acute respiratory distress syndrome requiring ECMO: a retrospective cohort study. Annals of Intensive Care, 2020, 10 (1), pp.158. ⟨10.1186/s13613-020-00775-4⟩. ⟨hal-03095037⟩