Bacterial and Fungal Superinfections in COVID-19 Patients Hospitalized in an Intensive Care Unit from Timișoara, Romania

Figures & data

Figure 1 Monthly distribution of the number of COVID-19 patients hospitalized in the ICU (Timișoara, Romania, October 2020–May 2021). (A) Percentage of the total number of cases with unfavorable/favorable outcome; (B) percentage of the total number of cases with infected/ uninfected status.

Table 1 Univariate Analysis of Factors Associated with Unfavorable Outcome in COVID-19 Patients Hospitalized in the ICU (Timișoara, Romania, October 2020–May 2021)

Variable	Group 1 – Patients with Unfavorable Outcome (N1=179)	Group 2 – Patients with Favorable Outcome (N2=57)	p	OR [95% CI]
Age, years (median [IQR])	68.00 [60.00–72.00]	60.00 [52.00–69.00]	0.001	1.05 [1.02–1.07]
Male gender [n (%)]	112(62.57)	27(47.37)	0.042	1.86 [1.02–3.39]
Days of hospitalization (median, [IQR])	9.00 [5.00–13.00]	9.00 [7.00–12.00]	0.927	1.00 [0.94–1.07]
Days with CVC [median, IQR]	8.00[4.00–11.00]	3.00[0.00–8.00]	<0.001	1.14 [1.07–1.22]
Days with peripheral venous catheter [median, IQR]	0.00[0.00–2.00]	4.00[0.00–8.00]	<0.001	0.787 [0.72–0.86]
Days with urinary catheter [median, IQR]	9.00[5.00–13.00]	8.00[7.00–12.00]	0.553	1.02 [0.96–1.08]
Number of comorbidities [median, IQR]	4.00[2.00–6.00]	3.00[2.00–5.00]	0.161	1.08[0.97–1.21]
Days of mechanical ventilation [median, IQR]	5.00[3.00–9.00]	0.00[0.00–2.00]	<0.001	1.31[1.18–1.46]
Days of non-invasive ventilation [median, IQR]	2.00[0.00–6.00]	3.00[0.00–6.00]	0.478	0.97[0.90–1.05]
Days of O2 therapy – face mask [median, IQR]	0.00[0.00–0.00]	4.00[1.00–5.00]	<0.001	0.37[0.28–0.49]
O2 saturation [median, IQR]	0.85[0.78–0.92]	0.90[0.80–0.96]	0.034	0.97[0.94–0.99]
Apache II score* [median, IQR]	13.00[9.00–18.00]	9.00[5.00–14.00]	0.003	1.08[1.03–1.14]
Carmeli score** [median, IQR]	2.00[2.00–2.00]	2.00[2.00–2.00]	0.016	3.14[1.24–7.99]
Charlson comorbidity index*** [median, IQR]	4.00[2.00–5.00]	2.00[1.00–4.00]	0.001	1.29[1.11–1.51]
Critical COVID-19 upon ICU admission [n, %]	67(37.43)	12(21.05)	0.022	2.24[1.11–4.54]
Severe COVID-19 upon ICU admission [n, %]	111(62.01)	41(71.93)	0.173	0.64[0.33–1.22]
Hiperimmune plasma administration [n, %]	5(2.79)	1(1.75)	1.00	1.61[0.18–14.06]
Prior antiviral treatment [n, %]	138(77.09)	44(77.19)	0.987	0.99[0.49–2.02]
Prior corticosteroid treatment [n, %]	138(77.09)	44(77.19)	0.987	0.99[0.49–2.02]
Tocilizumab [n, %]	7(3.91)	0(0)	0.200	ND
ARDS [n, %]	169(94.41)	37(64.91)	<0.001	9.14[3.95–21.13]
Superinfection [n, %]	88(49.16)	31(54.38)	0.492	0.81[0.45–1.47]
COVID-19 end-organ damages
Cardiac [n, %]	29(16.20)	4(7.02)	0.122	2.56[0.86–7.63]
Hepatic [n, %]	50(27.93)	11(19.30)	0.194	1.62[0.77–3.38]
Neurological [n, %]	45(25.14)	10(17.54)	0.237	1.58[0.74–3.38]
Pancreatic [n, %]	43(24.02)	7(12.28)	0.058	2.26[0.95–5.35]
Renal [n, %]	46(25.70)	5(8.77)	0.006	3.59[1.35–9.55]
ALT (U/L) [median, IQR]	39.00[27.00–68.00]	39.00[25.00–61.00]	0.623	1.00[0.99–1.00]
AST (U/L) [median, IQR]	52.00[34.00–89.00]	40.00[32.00–58.00]	0.308	1.00[0.99–1.00]
Serum creatinin (mg/dL) [median, IQR]	0.90[0.60–1.50]	0.70[0.60–0.90]	0.030	1.51[1.04–2.19]
D-Dimer (μg/mL) [median, IQR]	831.00[483.00–2745.00]	842.00[348.00–1850.00]	0.689	1.00[1.00–1.00]
Fibrinogen (mg/dL) [median, IQR]	452.00[317.00–581.00)	452.00[333.00–577.00]	0.859	1.00[0.99–1.00]
CRP (mg/L) [median, IQR]	140.30[58.60–248.00]	71.20[42.00–196.65]	0.018	1.00[1.00–1.01]
Blood glucose (mg/dL) [median, IQR]	170.00[133.00–237.00]	159.00[128.00–237.00]	0.291	1.00[0.99–1.01]
BMI (kg/m^2) [median, IQR]	28.00[24.00–34.80]	26.10[22.70–30.50]	0.035	1.05[1.00–1.11]
WBC (x1000/mm^3) [median, IQR]	17.60 [13.00–40.00]	16.00 [11.60–25.70]	0.047	1.05[1.00–1.10]
Procalcitonin (ng/mL) [median, IQR]	0.50[0.50–1.00]	0.50[0.50–0.50]	0.115	1.12[0.97–1.28]
Comorbidities
Cardiac disease [n, %]	99(55.31)	20(35.09)	0.007	2.29[1.23–4.25]
Hypertension [n, %]	132(73.74)	29(50.88)	0.001	2.71[1.46–5.02]
Cronic respiratory disease [n, %]	24(13.41)	8(14.04)	0.904	0.95[0.40–2.46]
Chronic kidney disease [n, %]	19(10.61)	2(3.51)	0.116	3.26[0.74–14.47]
Neurological/ neuromuscular disease [n, %]	31(17.32)	8(14.04)	0.561	1.28[0.55–2.98]
Peptic ulcer disease [n, %]	1(0.56)	1(1.75)	0.425	0.31[0.02–5.11]
Coagulopathy [n, %]	8(4.47)	1(1.75)	0.691	2.62[0.32–21.41]
Diabetes [n, %]	58(32.40)	22(38.60)	0.389	0.76[0.41–1.42]
Liver disease [n, %]	27(15.08)	4(7.02)	0.175	2.35[0.78–7.04]
Pregnancy [n, %]	1(0.56)	0(0)	1.00	ND
Postpartum [n, %]	2(1.12)	0(0)	1.00	ND
Imunodeficiency [n, %]	4(2.23)	1(1.75)	1.00	1.28[0.14–11.69]
Autoimune disease [n, %]	14(7.82)	4(7.02)	1.00	1.12[0.35–3.56]
Obesity [n, %]	71(39.66)	15(26.32)	0.068	1.84[0.95–3.57]
Overweight [n, %]	45(25.14)	15(26.32)	0.859	0.94[0.48–1.86]
Oncological disease [n, %]	22(12.29)	3(5.26)	0.214	2.52[0.73–8.76]
Psychiatric patology [n, %]	6(3.35)	2(3.51)	1.00	0.95[0.19–4.86]
Urinary catheterization [n, %]	179(100)	57(100)	/	ND
CVC [n, %]	169(94.41)	30(52.63)	<0.001	15.21[6.68–34,63]
Peripheral venous catheterization [n, %]	76(42.46)	41(71.93)	<0.001	0.29[0.15–0.55]
Diaysis [n, %]	31(17.32)	1(1.75)	0.001	11.73[1.56–87.98]
Gastrostomy [n, %]	1(0.56)	0(0)	1.00	ND
Enteral nutrition [n, %]	173(96.65)	48(84.21)	<0.001	5.41[1.83–15.94]
Tracheostomy [n, %]	3(1.68)	0(0)	1.00	ND
Without antibiotherapy [n, %]	10(5.58)	6(10.52)	0.196	0.50[0.17–1.45]

Notes: *APACHE II (“Acute Physiology and Chronic Health Evaluation II”) is a severity-of-disease classification system which is applied to a patient admitted into the ICU during the first 24 hours. It ranges from 0 to 71 and is based on multiple measurements. The higher the score, the more severe the disease and the risk of death increases. 12 admission physiologic variables, the patient’s age and chronic health status are used to compute the score.¹⁷ **Carmeli’s score is a marker related both to age, comorbidities and to contact with the hospital environment and can be used for assessing the expected sensitivity to antibiotics in bacterial infections.¹⁸ ***The Charlson comorbidity index predicts the 1 year mortality of patients with a wide range of comorbidities. The score sums up 19 comorbidities weighted according to severity. The higher the score, the higher the mortality.¹⁹

Abbreviations: n, number; CVC, central venous catheter; ALT, alanine transaminase; AST, aspartate aminotransferase; ARDS, acute respiratory distress syndrome, CRP, C reactive protein; BMI, body mass index; WBC, white blood cells; ND, not defined.

Table 2 Univariate Analysis of Factors Associated with Superinfection in COVID-19 Patients Hospitalized in the ICU (Timișoara, Romania, October 2020–May 2021)

Variable	Group 3 – Patients with Bacterial/ Fungal Infection (N3=119)	Group 4 – Patients Without Bacterial/Fungal Infection (N4=117)	p	OR [95% CI]
Age, years (median [IQR])	65.00[54.00–70.00]	68.00[60.00–73.00]	0.006	0.97[0.95–0.99]
Male gender [n (%)]	70(58.82)	69(58.97)	0.981	0.99[0.59–1.67]
Days of hospitalization (median, [IQR])	11.00[7.00–15.00]	8.00[5.00–12.00]	<0.001	1.12[1.06–1.19]
Days with CVC [median, IQR]	10.00[4.00–14.00]	4.00[2.00–8.00]	<0.001	1.15[1.09–1.21]
Days with peripheral venous catheter [median, IQR]	0.00[0.00–2.00]	1.00[0.00–5.00]	0.004	0.89[0.82–0.96]
Days with urinary catheter [median, IQR]	11.00[7.00–14.00]	8.00[4.00–11.00]	<0.001	1.12[1.06–1.19]
Number of comorbidities [median, IQR]	3.00[2.00–6.00]	3.00[2.00–6.00]	0.849	1.01[0.92–1.10]
Days of mechanical ventilation [median, IQR]	6.00[1.00–10.00]	3.00[1.00–6.00]	<0.001	1.15[1.08–1.23]
Days of non-invasive ventilation [median, IQR]	1.00[0.00–6.00]	2.00[0.00–6.00]	0.528	0.98[0.91–1.05]
Days of O2 therapy – face mask [median, IQR]	0.00[0.00–1.00]	0.00[0.00–1.00]	0.468	0.96[0.86–1.07]
O2 saturation [median, IQR]	0.85[0.80–0.92]	0.88[0.85–0.91]	0.001	0.003[0.00–0.09]
Apache II score [median, IQR]	12.00[9.00–18.00]	12.00[8.00–17.00]	0.801	1.00[0.97–1.04]
Carmeli score [median, IQR]	2.00[2.00–2.00]	2.00[2.00–2.00]	0.081	1.81[0.93–3.54]
Charlson score [median, IQR]	3.00[2.00–4.00]	4.00[2.00–5.00]	0.111	0.92[0.82–1.02]
Critical COVID-19 upon ICU admission [n, %]	53(44.54)	26(22.22)	<0.001	2.81[1.59–4.95]
Severe COVID-19 upon ICU admission [n, %]	64(53.78)	88(75.21)	<0.001	0.38[0.22–0.67]
Hiperimmune plasma administration [n, %]	6(5.04)	0(0)	0.029	Nedefinit
Prior corticosteroid treatment [n, %]	101(84.87)	81(69.23)	0.004	2.49[1.32–4.71]
Tocilizumab [n, %]	4(3.36)	3(2.56)	1.00	1.32[0.29–6.04]
ARDS [n, %]	101(84.87)	105(89.74)	0.261	0.64[0.29–1.39]
COVID-19 organ damages
Cardiac [n, %]	20(16.81)	13(11.11)	0.260	1.61[0.76–3.42]
Hepatic [n, %]	36(30.25)	25(21.37)	0.119	1.59[0.88–2.88]
Neurological [n, %]	29(24.37)	26(22.22)	0.696	1.13[0.61–2.06]
Pancreatic [n, %]	28(23.53)	22(18.80)	0.374	1.33[0.71–2.49]
Renal [n, %]	24(20.17)	27(23.08)	0.587	0.84[0.45–1.57]
ALT (U/L) [median, IQR]	39.00[23.00–69.00]	38[29.00–63.00]	0.332	0.99[0.99–1.00]
AST (U/L) [median, IQR]	53.00[34.00–86.00]	45.00[33.00–69.00]	0.332	1.00[0.99–1.00]
Serum creatinin (mg/dL) [median, IQR]	0.80[0.60–1.20]	0.80[0.60–1.30]	0.267	0.94[0.85–1.05]
D-Dimer (μg/mL) [median, IQR]	834.00[428–2578]	831.00[502–2745]	0.708	1.00[1.00–1.00]
Fibrinogen (mg/dL) [median, IQR]	452.00[345–591]	452.00[303–588]	0.427	1.00[0.99–1.00]
CRP (mg/L) [median, IQR]	89.00[44.00–268.00]	90.00[55.00–226.00]	0.228	1.00[0.99–1.00]
Blood glucose (mg/dL) [median, IQR]	170.00[131–225]	168.00[137–243.00]	0.064	0.99[0.99–1.00]
BMI (kg/m^2) [median, IQR]	27.00[23.60–31.00]	28.00[24.00–35.60]	0.144	0.97[0.93–1.01]
WBC (x1000/mm^3) [median, IQR]	17.20[12.50–4.90]	17.80[13.10–5.50]	0.642	1.00[0.99–1.00]
Procalcitonin (ng/mL) [median, IQR]	0.50[0.50–1.50]	0.50[0.50–0.50]	0.020	1.12[1.02–1.24]
Hyperglicemia [n, %]	89(74.79)	99(84.62)	0.060	0.54[0.28–1.03]
Comorbidities
Cardiac disease [n, %]	50(42.02)	69(58.97)	0.009	0.50[0.30–0.85]
Hypertension [n, %]	79(66.39)	82(70.09)	0.542	0.84[0.49–1.46]
Cronic respiratory disease [n, %]	17(14.29)	15(12.82)	0.742	1.13[0.54–2.39]
Chronic kidney disease [n, %]	11(9.24)	10(8.55)	0.851	1.09[0.44–2.67]
Neurological/ neuromuscular disease [n, %]	19(15.97)	20(17.09)	0.815	0.92[0.46–1.83]
Peptic ulcer disease [n, %]	2(1.69)	0(0)	0.497	Nedefinit
Coagulopathy [n, %]	3(2.52)	6(5.13)	0.295	0.48[0.17–1.96]
Diabetes [n, %]	37(31.09)	43(36.75)	0.358	0.78[0.45–1.33]
Liver disease [n, %]	17(14.29)	14(11.97)	0.597	1.23[0.57–2.62]
Pregnancy [n, %]	1(0.84)	0(0)	1.00	ND
Postpartum [n, %]	2(1.69)	0(0)	0.497	ND
Imunodeficiency [n, %]	3(2.52)	2(1.71)	1.00	1.49[0.24–9.06]
Autoimune disease [n, %]	8(6.72)	10(8.55)	0.597	0.77[0.29–2.03]
Obesity [n, %]	38(31.93)	48(41.03)	0.146	0.67[0.39–1.15]
Overweight [n, %]	30(25.21)	30(25.64)	0.939	0.98[0.54–1,76]
Oncological disease [n, %]	16(13.45)	9(7.69)	0.151	1.86[0.79–4.41]
Psychiatric patology [n, %]	7(5.88)	1(0.85)	0.065	7.25[0.87–59.88]
Urinary catheterization [n, %]	119(100)	117(100)	/	/
CVC [n, %]	108(90.76)	91(77.78)	0.006	2.80[1.31–5.98]
Peripheral venous catheterization [n, %]	49(41.18)	68(58.12)	0.009	0.50[0.30–0.85]
Diaysis [n, %]	18(15.13)	14(11.97)	0.478	1.31[0.62–2.78]
Gastrostomy [n, %]	1(0.84)	0(0)	1.00	ND
Enteral Nutrition [n, %]	114(95.80)	107(91.45)	0.171	2.13[0.71–6.44]
Tracheostomy [n, %]	2(1.68)	1(0.85)	1.00	0.98[0.14–7.09]
Unfavorable outcome* [n, %]	89(74.78)	90(76.92)	0.701	0.89[0.49–1.62]
No antibiotics [n, %]	3(2.52)	13(11.11)	0.009	0.21[0.06–0.075]
1 antibiotic [n, %]	25(21.01)	55(47.01)	<0.001	0.29[0.17–0.53]
2 antibiotics [n, %]	26(21.85)	30(25.64)	0.493	0.81[0.44–1.48]
3 antibiotics [n, %]	38(31.93)	13(11.11)	<0.001	3.75[1.87–7.51]
4 antibiotics [n, %]	17(14.29)	3(2.56)	0.001	6.33[1.80–22.24]

Notes: *Unfavorable outcome = deceased + aggravated (We considered a patient aggravated if one of the following occurred: escalating the form of respiratory support from non-invasive ventilation to invasive mechanical ventilation, development of a new organ failure, development of septic shock and increased need for vasoactive drugs).

Abbreviations: n, number; CVC, central venous catheter; ARDS, acute respiratory distress syndrome; ALT, alanine transaminase; AST, aspartate aminotransferase; CRP, C reactive protein; BMI, body mass index; WBC, white blood cells; ND, not defined.

Table 3 Distribution of Microbial Strains and Main Resistance Phenotypes Isolated from the Biological Samples Drawn from Infected COVID-19 Patients Hospitalized in the ICU (Timișoara, Romania, October 2020–May 2021)

Species Biological Product	Tracheobronchial Aspirate n=65	Blood n=48	Urine n=24	Sputum n=9	Wound Swab n=4	Other n=7	Feces n=26
No pathogen [n, %]	9(13.85)	2(4.17)	13(54.17)	3(33.33)	/	1(14.28)	/
Acinetobacter baumannii [n, %]	26(40.00)	5(10.42)	/	1(11.11)	1(25.00)	2(28.57)	/
Klebsiella pneumoniae [n, %]	8(12.31)	1(2.08)	2(8.33)	1(11.11)	/	1(14.28)	/
Klebsiella spp (other than K. pneumoniae) [n, %]	1(1.54)	2(4.17)	1(4.17)	1(11.11)	/	1(14.28)	/
Enterococcus faecalis [n, %]	3(4.61)	7(14.58)	/	/	/	/	/
Enterococcus faecium [n, %]	/	5(10.42)	/	/	/	/	/
Enterococcus spp (other than E. faecalis and E. faecium) [n, %]	2(3.08)	2(4.17)	5(20.83)	/	2(50.00)	1(14.28)	/
Pseudomonas aeruginosa [n, %]	5(7.69)	/	2(8.33)	1(11.11)	1(25.00)	1(14.28)	/
Enterobacter cloacae [n, %]	4(6.15)	/	/	/	/	/	/
Escherichia coli [n, %]	2(3.08)	1(2.08)	1(4.17)	/	/	/	/
Staphylococcus aureus [n, %]	9(13.85)	/	/	/	/	/	/
CoNS^a [n, %]	/	29(60.42)	/	/	1(25.00)	1(14.28)	/
Other strains^b [n, %]	6(9.23)	2(4.17)	/	2(22.22)	2(50.00)	1(14.28)	/
Clostridioides difficile [n, %]	/	/	/	/	/	/	26(100)
Candida spp^c [n, %]	11(16.92)	2(4.17)	13(54.17)	3(33.33)	/	2(28.57)	/
ESBLE* [n, %]	30(58.82)	6(54.54)	4(36.36)	2(50.00)	2(66.67)	4(80.00)	/
CRO* [n, %]	30(58.82)	4(36.36)	2(18.18)	2(50.00)	1(33.33)	4(80.00)	/
MRSA** [n, %]	6(66.67)	/	/	/	/	/	/
MR-CoNS** [n, %]	/	23(79.31)	/	/	1(100)	1(100)	/
VRE** [n, %]	1(20.00)	1(7.14)	0(0)	/	0(0)	/	/
MDR*** [n, %]	21(31.82)	30(55.55)	3(27.27)	1(16.67)	0(0)	5(62.50)	/
XDR*** [n, %]	25(37.88)	5(9.26)	2(18.18)	2(33.33)	1(14.28)	2(25.00)	/

Notes: ^aCoNS strains included - Staphylococcus epidermidis, Staphylococcus hominis, Staphylococcus haemolythicus. ^bOther strains included - Proteus mirabilis, Sphingomonas paucimobilis, Stenotrophomonas maltophilia, Hafnia alvei, Group C, G beta hemolytic Streptococcus, Serratia odorifera etc. ^cCandida spp strains included Candida albicans, Candida glabrata, Candida krusei, Candida tropicalis, Candida dubliniensis, Candida parapsilosis. *Percentages related to the number of Gram negative strains. **Percentages related to the number of strains from the respective species/genus. ***Percentages related to the total number of bacterial strains isolated from the biological product.

Abbreviations: n, number; CoNS, coagulase-negative staphylococci; ESBLE, extended spectrum beta-lactamase Enterobacterales; CRO, carbapenem-resistant organisms; MRSA, methicillin-resistant Staphylococcus aureus; MR-CoNS, methicillin-resistant coagulase-negative Staphylococci; VRE, vancomycin-resistant Enterococcus; MDR, multi-drug resistant; XDR, extensively drug-resistant.

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