RESUMEN
BACKGROUND: Empirical broad-spectrum antibiotics are frequently prescribed to patients with severe COVID-19, motivated by concern about bacterial coinfection. There is no evidence of benefit from such a strategy, while the dangers of inappropriate antibiotics are well described. OBJECTIVES: To investigate the frequency, profile and related outcomes of infections by bacterial pathogens in patients admitted to an intensive care unit (ICU) with severe COVID-19 pneumonia. METHODS: This was a prospective, descriptive study in a dedicated COVID-19 ICU in Cape Town, South Africa, involving all adult patients admitted to the ICU with confirmed COVID-19 pneumonia between 26 March and 31 August 2020. We collected data on patient comorbidities, laboratory results, antibiotic treatment, duration of admission and in-hospital outcome. RESULTS: We included 363 patients, who collectively had 1 199 blood cultures, 308 tracheal aspirates and 317 urine cultures performed. We found positive cultures for pathogens in 20 patients (5.5%) within the first 48 hours of ICU admission, while 73 additional patients (20.1%) had positive cultures later during their stay. The most frequently isolated pathogens at all sites were Acinetobacter baumannii (n=54), Klebsiella species (n=13) and coagulase-negative staphylococci (n=9). Length of ICU stay (p<0.001) and intubation (p<0.001) were associated with positive cultures on multivariate analysis. Disease severity (p=0.5), early antibiotic use (p=0.5), diabetes mellitus (p=0.1) and HIV (p=0.9) were not associated with positive cultures. Positive cultures, particularly for tracheal aspirates (p<0.05), were associated with longer ICU length of stay and mortality. Early empirical antibiotic use was not associated with mortality (odds ratio 2.5; 95% confidence interval 0.95 - 6.81). CONCLUSIONS: Bacterial coinfection was uncommon in patients at the time of admission to the ICU with severe COVID-19. Avoiding early empirical antibiotic therapy is therefore reasonable. Strategies to avoid coinfection and outbreaks in hospital, such as infection prevention and control, as well as the strict use of personal protective equipment, are important to improve outcomes.
Asunto(s)
Antibacterianos/administración & dosificación , Infecciones Bacterianas/tratamiento farmacológico , COVID-19/complicaciones , Unidades de Cuidados Intensivos , Adulto , Bacterias/aislamiento & purificación , Infecciones Bacterianas/epidemiología , Infecciones Bacterianas/microbiología , Humanos , Prescripción Inadecuada , Tiempo de Internación , Persona de Mediana Edad , Neumonía Viral , Pautas de la Práctica en Medicina , Estudios Prospectivos , SudáfricaRESUMEN
BACKGROUND: In resource-limited setting, there is scarce evidence comparing antiretroviral therapy (ART) outcomes among HIV-infected adolescents to that of other age groups. METHODS AND STUDY DESIGN: We analysed data from 25 ART facilities in Lusaka District, comparing treatment-naïve ART-eligible young adolescents (10-14 years), older adolescents (15-19) and young adults (20-24 years) initiating first-line ART to those aged 24 years or older. The adjusted relative risk (RR) of failure to achieve an adequate CD4 response (defined as failure to increase CD4 count by ≥ 50 cells/mm3 at 6 months or by ≥ 100 cells/mm3) at 6 or 12 months after ART initiation was modelled using log-binomial regression. The effect of age group on mortality and loss to follow-up (LTFUP; ≥60 days since scheduled visit date) was estimated using adjusted Cox proportional hazards models, respectively. This was a routine retrospective design using program data. RESULTS: Of the 94,023 patients initiating ART from May 2004 to February 2011, 1303 (1.4%) were young adolescents, 1440 (1.5%) were older adolescents and 5825 (6.2%) were young adults. 85,455 (90.9%) were 24 years or older at the time of ART initiation. Compared with adults, both young adolescents (RR: 0.88, 95% confidence interval [CI]: 0.76-1.01 at 6 months and RR: 0.80, 95% CI: 0.69-0.93 at 12 months) and older adolescents (RR: 0.82, 95% CI: 0.71-0.95 at 6 months) were less likely to achieve adequate CD4 response. No evidence of a difference in mortality risk was observed among older adolescents (hazard ratio [HR] 1.20, 95% CI: 0.93-1.56) compared with adults; however, there was a reduced risk of mortality in young adolescents compared with adults (HR: 0.61, 95% CI: 0.40-0.92). Young adolescents were less likely to be LTFUP following ART initiation (HR: 0.74, 95% CI: 0.59-0.92), while older adolescents and young adults were reported to be more likely to drop out of care (HR: 1.54 95% CI: 1.33-1.78; HR: 1.51 95% CI: 1.40-1.63 respectively). CONCLUSION: Older adolescents and young adults had poorer ART treatment outcomes, including failure to achieve adequate CD4 recovery and failure to remain in long-term care, when compared with adults. Interventions are necessary to help increase outcomes and retention in care.