Community-Onset Bacterial Coinfection in Children Critically Ill With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

Kristin L Moffitt; Mari M Nakamura; Cameron C Young; Margaret M Newhams; Natasha B Halasa; J Nelson Reed; Julie C Fitzgerald; Philip C Spinella; Vijaya L Soma; Tracie C Walker; Laura L Loftis; Aline B Maddux; Michele Kong; Courtney M Rowan; Charlotte V Hobbs; Jennifer E Schuster; Becky J Riggs; Gwenn E McLaughlin; Kelly N Michelson; Mark W Hall; Christopher J Babbitt; Natalie Z Cvijanovich; Matt S Zinter; Mia Maamari; Adam J Schwarz; Aalok R Singh; Heidi R Flori; Shira J Gertz; Mary A Staat; John S Giuliano Jr; Saul R Hymes; Katharine N Clouser; John McGuire; Christopher L Carroll; Neal J Thomas; Emily R Levy; Adrienne G Randolph

doi:10.1093/ofid/ofad122

Community-Onset Bacterial Coinfection in Children Critically Ill With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

Open Forum Infect Dis. 2023 Mar 6;10(3):ofad122. doi: 10.1093/ofid/ofad122. eCollection 2023 Mar.

Authors

Kristin L Moffitt^{1

2}, Mari M Nakamura^{1

2

3}, Cameron C Young⁴, Margaret M Newhams⁴, Natasha B Halasa⁵, J Nelson Reed⁶, Julie C Fitzgerald⁷, Philip C Spinella⁸, Vijaya L Soma⁹, Tracie C Walker¹⁰, Laura L Loftis¹¹, Aline B Maddux¹², Michele Kong¹³, Courtney M Rowan¹⁴, Charlotte V Hobbs¹⁵, Jennifer E Schuster¹⁶, Becky J Riggs¹⁷, Gwenn E McLaughlin¹⁸, Kelly N Michelson¹⁹, Mark W Hall²⁰, Christopher J Babbitt²¹, Natalie Z Cvijanovich²², Matt S Zinter²³, Mia Maamari²⁴, Adam J Schwarz²⁵, Aalok R Singh²⁶, Heidi R Flori²⁷, Shira J Gertz²⁸, Mary A Staat²⁹, John S Giuliano Jr³⁰, Saul R Hymes³¹, Katharine N Clouser³², John McGuire³³, Christopher L Carroll³⁴, Neal J Thomas³⁵, Emily R Levy³⁶, Adrienne G Randolph^{2

4

37}

Affiliations

¹ Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA.
² Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
³ Antimicrobial Stewardship Program, Boston Children's Hospital, Boston, Massachusetts, USA.
⁴ Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.
⁵ Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
⁶ Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA.
⁷ Division of Critical Care, Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
⁸ Division of Critical Care, Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
⁹ Division of Pediatric Infectious Diseases, Department of Pediatrics, New York University Grossman School of Medicine, Hassenfeld Children's Hospital, New York, New York, USA.
¹⁰ Department of Pediatrics, University of North Carolina at Chapel Hill Children's Hospital, Chapel Hill, North Carolina, USA.
¹¹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
¹² Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA.
¹³ Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA.
¹⁴ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.
¹⁵ Department of Pediatrics, Division of Disease, University of Mississippi Medical Center, Jackson, Mississippi, USA.
¹⁶ Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri, USA.
¹⁷ Division of Pediatric Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
¹⁸ Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA.
¹⁹ Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
²⁰ Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA.
²¹ Miller Children's and Women's Hospital of Long Beach, Long Beach, California, USA.
²² Division of Critical Care Medicine, University of California, San Francisco Benioff Children's Hospital, Oakland, California, USA.
²³ School of Medicine, Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California, USA.
²⁴ Department of Pediatrics, Division of Critical Care Medicine, University of Texas Southwestern, Children's Health Medical Center Dallas, Dallas, Texas, USA.
²⁵ Division of Critical Care Medicine, Children's Hospital Orange County, Orange, California, USA.
²⁶ Pediatric Critical Care Division, Maria Fareri Children's Hospital at Westchester Medical Center and New York Medical College, Valhalla, New York, USA.
²⁷ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan, USA.
²⁸ Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, New Jersey, USA.
²⁹ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
³⁰ Department of Pediatrics, Division of Critical Care, Yale University School of Medicine, New Haven, Connecticut, USA.
³¹ Division of Pediatric Infectious Diseases, Stony Brook Children's Hospital, Renaissance School of Medicine, Stony Brook, New York, USA.
³² Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA.
³³ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and the University of Washington, Seattle, Washington, USA.
³⁴ Division of Critical Care, Connecticut Children's, Hartford, Connecticut, USA.
³⁵ Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA.
³⁶ Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA.
³⁷ Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts, USA.

Abstract

Background: Community-onset bacterial coinfection in adults hospitalized with coronavirus disease 2019 (COVID-19) is reportedly uncommon, though empiric antibiotic use has been high. However, data regarding empiric antibiotic use and bacterial coinfection in children with critical illness from COVID-19 are scarce.

Methods: We evaluated children and adolescents aged <19 years admitted to a pediatric intensive care or high-acuity unit for COVID-19 between March and December 2020. Based on qualifying microbiology results from the first 3 days of admission, we adjudicated whether patients had community-onset bacterial coinfection. We compared demographic and clinical characteristics of those who did and did not (1) receive antibiotics and (2) have bacterial coinfection early in admission. Using Poisson regression models, we assessed factors associated with these outcomes.

Results: Of the 532 patients, 63.3% received empiric antibiotics, but only 7.1% had bacterial coinfection, and only 3.0% had respiratory bacterial coinfection. In multivariable analyses, empiric antibiotics were more likely to be prescribed for immunocompromised patients (adjusted relative risk [aRR], 1.34 [95% confidence interval {CI}, 1.01-1.79]), those requiring any respiratory support except mechanical ventilation (aRR, 1.41 [95% CI, 1.05-1.90]), or those requiring invasive mechanical ventilation (aRR, 1.83 [95% CI, 1.36-2.47]) (compared with no respiratory support). The presence of a pulmonary comorbidity other than asthma (aRR, 2.31 [95% CI, 1.15-4.62]) was associated with bacterial coinfection.

Conclusions: Community-onset bacterial coinfection in children with critical COVID-19 is infrequent, but empiric antibiotics are commonly prescribed. These findings inform antimicrobial use and support rapid de-escalation when evaluation shows coinfection is unlikely.

Keywords: SARS-CoV-2; antimicrobial stewardship; bacterial coinfection; pediatric COVID-19; pneumonia.

Grants and funding

K23 DK119463/DK/NIDDK NIH HHS/United States