Saad Alhumaid1, Abbas Al Mutair2,3,4, Zainab Al Alawi5, Abeer M Alshawi6, Salamah A Alomran6, Mohammed S Almuhanna7, Anwar A Almuslim7, Ahmed H Bu Shafia8, Abdullah M Alotaibi9, Gasmelseed Y Ahmed2, Ali A Rabaan10, Jaffar A Al-Tawfiq11,12,13, Awad Al-Omari14,15. 1. Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Ministry of Health, Al-Ahsa 31982, Saudi Arabia. 2. Research Center, Almoosa Specialist Hospital, Al-Ahsa 36342, Saudi Arabia. 3. College of Nursing, Princess Norah Bint Abdul Rahman University, Riyadh 11564, Saudi Arabia. 4. School of Nursing, University of Wollongong, Wollongong, NSW 2522, Australia. 5. Division of Allergy and Immunology, College of Medicine, King Faisal University, Al-Ahsa 31982, Saudi Arabia. 6. Department of Pharmacy, King Fahad Hofuf Hospital, Al-Ahsa 36441, Saudi Arabia. 7. Department of Pharmacy, Maternity and Children Hospital, Al-Ahsa 36422, Saudi Arabia. 8. Department of Pharmacy, Alomran Hospital, Al-Ahsa 36355, Saudi Arabia. 9. Department of Pharmacy, Prince Sultan Cardiac Center, Al-Ahsa 36441, Saudi Arabia. 10. Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia. 11. Infectious Disease Unit, Specialty Internal Medicine, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia. 12. Infectious Disease Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA. 13. Infectious Disease Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA. 14. College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia. 15. Research Center, Dr. Sulaiman Al Habib Medical Group, Riyadh 11372, Saudi Arabia.
Abstract
BACKGROUND: Coinfection with bacteria, fungi, and respiratory viruses in SARS-CoV-2 is of particular importance due to the possibility of increased morbidity and mortality. In this meta-analysis, we calculated the prevalence of such coinfections. METHODS: Electronic databases were searched from 1 December 2019 to 31 March 2021. Effect sizes of prevalence were pooled with 95% confidence intervals (CIs). To minimize heterogeneity, we performed sub-group analyses. RESULTS: Of the 6189 papers that were identified, 72 articles were included in the systematic review (40 case series and 32 cohort studies) and 68 articles (38 case series and 30 cohort studies) were included in the meta-analysis. Of the 31,953 SARS-CoV-2 patients included in the meta-analysis, the overall pooled proportion who had a laboratory-confirmed bacterial infection was 15.9% (95% CI 13.6-18.2, n = 1940, 49 studies, I2 = 99%, p < 0.00001), while 3.7% (95% CI 2.6-4.8, n = 177, 16 studies, I2 = 93%, p < 0.00001) had fungal infections and 6.6% (95% CI 5.5-7.6, n = 737, 44 studies, I2 = 96%, p < 0.00001) had other respiratory viruses. SARS-CoV-2 patients in the ICU had higher co-infections compared to ICU and non-ICU patients as follows: bacterial (22.2%, 95% CI 16.1-28.4, I2 = 88% versus 14.8%, 95% CI 12.4-17.3, I2 = 99%), and fungal (9.6%, 95% CI 6.8-12.4, I2 = 74% versus 2.7%, 95% CI 0.0-3.8, I2 = 95%); however, there was an identical other respiratory viral co-infection proportion between all SARS-CoV-2 patients [(ICU and non-ICU) and the ICU only] (6.6%, 95% CI 0.0-11.3, I2 = 58% versus 6.6%, 95% CI 5.5-7.7, I2 = 96%). Funnel plots for possible publication bias for the pooled effect sizes of the prevalence of coinfections was asymmetrical on visual inspection, and Egger's tests confirmed asymmetry (p values < 0.05). CONCLUSION: Bacterial co-infection is relatively high in hospitalized patients with SARS-CoV-2, with little evidence of S. aureus playing a major role. Knowledge of the prevalence and type of co-infections in SARS-CoV-2 patients may have diagnostic and management implications.
BACKGROUND:Coinfection with bacteria, fungi, and respiratory viruses in SARS-CoV-2 is of particular importance due to the possibility of increased morbidity and mortality. In this meta-analysis, we calculated the prevalence of such coinfections. METHODS: Electronic databases were searched from 1 December 2019 to 31 March 2021. Effect sizes of prevalence were pooled with 95% confidence intervals (CIs). To minimize heterogeneity, we performed sub-group analyses. RESULTS: Of the 6189 papers that were identified, 72 articles were included in the systematic review (40 case series and 32 cohort studies) and 68 articles (38 case series and 30 cohort studies) were included in the meta-analysis. Of the 31,953 SARS-CoV-2patients included in the meta-analysis, the overall pooled proportion who had a laboratory-confirmed bacterial infection was 15.9% (95% CI 13.6-18.2, n = 1940, 49 studies, I2 = 99%, p < 0.00001), while 3.7% (95% CI 2.6-4.8, n = 177, 16 studies, I2 = 93%, p < 0.00001) had fungal infections and 6.6% (95% CI 5.5-7.6, n = 737, 44 studies, I2 = 96%, p < 0.00001) had other respiratory viruses. SARS-CoV-2patients in the ICU had higher co-infections compared to ICU and non-ICU patients as follows: bacterial (22.2%, 95% CI 16.1-28.4, I2 = 88% versus 14.8%, 95% CI 12.4-17.3, I2 = 99%), and fungal (9.6%, 95% CI 6.8-12.4, I2 = 74% versus 2.7%, 95% CI 0.0-3.8, I2 = 95%); however, there was an identical other respiratoryviral co-infection proportion between all SARS-CoV-2patients [(ICU and non-ICU) and the ICU only] (6.6%, 95% CI 0.0-11.3, I2 = 58% versus 6.6%, 95% CI 5.5-7.7, I2 = 96%). Funnel plots for possible publication bias for the pooled effect sizes of the prevalence of coinfections was asymmetrical on visual inspection, and Egger's tests confirmed asymmetry (p values < 0.05). CONCLUSION:Bacterial co-infection is relatively high in hospitalized patients with SARS-CoV-2, with little evidence of S. aureus playing a major role. Knowledge of the prevalence and type of co-infections in SARS-CoV-2patients may have diagnostic and management implications.
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