Primary Respiratory Bacterial Coinfections in Patients with COVID-19

Waqas Ahmed Chauhdary Department of Medicine
PMMPHAMB Hospital
Tutong, Brunei Darussalam
National Isolation Centre
Tutong, Brunei Darussalam

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Pui Lin Chong Department of Medicine
RIPAS Hospital
Bandar Seri Begawan, Brunei Darussalam

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Babu Ivan Mani Department of Medicine
PMMPHAMB Hospital
Tutong, Brunei Darussalam
National Isolation Centre
Tutong, Brunei Darussalam

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Rosmonaliza Asli Department of Medicine
RIPAS Hospital
Bandar Seri Begawan, Brunei Darussalam

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Riamiza Natalie Momin Department of Medicine
RIPAS Hospital
Bandar Seri Begawan, Brunei Darussalam

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Muhammad Syafiq Abdullah Department of Medicine
RIPAS Hospital
Bandar Seri Begawan, Brunei Darussalam

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Vui Heng Chong Department of Medicine
PMMPHAMB Hospital
Tutong, Brunei Darussalam
National Isolation Centre
Tutong, Brunei Darussalam
Department of Medicine
RIPAS Hospital
Bandar Seri Begawan, Brunei Darussalam
E-mail: vuiheng.chong@moh.gov.bn

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Dear Sir,

We read with interest the case report by Khaddour et al.,1 which reported a case of coinfection that led to delayed diagnosis of COVID-19. This case highlighted the importance of considering primary coinfection in patients with COVID-19.1 As the pandemic continues, the number of coinfections will increase. Not considering or testing for other respiratory pathogens can lead to delayed diagnosis that may lead to detrimental outcomes. We report our experience with bacterial respiratory coinfections in patients with COVID-19 with varying outcomes.

Of 141 confirmed cases of COVID-19 isolated and treated in Brunei Darussalam, five (3.5%) patients were found to have primary respiratory bacterial coinfections at different stages of illness (Table 1). Four were symptomatic, and one developed symptoms after admission. All had productive cough with purulent sputum. Only one case (Case 1) had complications (septic shock, and respiratory and renal failure) that required transfer to the intensive care unit. He eventually died of Staphylococcus aureus septicemia and COVID-19. Four patients were discharged after testing (reverse transcription-PCR) negative two consecutive times at least 24 hours apart.

Figure 1.
Figure 1.

Chest radiographs. (A) Day 3 of hospitalization which was normal and (B) day 5 which showed bilateral consolidations.

Citation: The American Journal of Tropical Medicine and Hygiene 103, 2; 10.4269/ajtmh.20-0498

Table1

Summary of demographic, investigation, and outcomes of patients

CaseAge (years)/genderSource of COVID-19Comorbid conditionsSymptoms at diagnosisCoinfection pathogenSitesCXR (time of investigation)Treatment (duration of treatment)Outcomes (time of event)
164/MTravelHypertension, dyslipidemia, thalassemia, and goutFever, chills, cough, and dyspnea (symptoms improved at admission)Staphylococcus aureusBlood sputum (+ve Gram stain) (day 1)Normal (day 3) and consolidation bilaterally (day 5)Oseltamivir (5 days), ciprofloxacin (3 days), lopinavir/ritonavir (11 days), hydroxychloroquine (5 days), piperacillin/tazobactam (7 days), and vancomycin (until death)Septic shock, acute kidney injury, intensive care unit admission (day 4), intubation (day 4), dialysis (day 6), died of multi-organ failure, and septicemia (day 16)
261/MReligious gatheringHypertension, dyslipidemia, chronic constipation, and cervical spondylosisPresymptomaticKlebsiella pneumonia and methicillin-resistant Staphylococcus aureusSputum (day 1)Normal (day-1), consolidation right side (day 7), and normal (day-15)Oseltamivir (5 days), ceftriaxone (3 days), piperacillin/tazobactam (7 days), lopinavir/ritonavir (14 days)Alive and discharged (day 17)
363/MReligious gatheringDiabetes, dyslipidemia, Hypertension, and AF post-ablationFever, cough, and rhinorrheaEnterobacter gergoviae and Rothia mucilaginosaSputum (day 1)Normal (day 1)Oseltamivir (5 days) and monitored and no treatmentAlive and discharged (day 24)
442/MTravelNilFever, cough, dyspnea, rhinorrhea, and myalgiaStreptococcus pneumoniaeSputum (day 1)Normal (day 1)Oseltamivir (5 days) and amoxicillin (7 days)Alive and discharged (day 17)
529/FPositive contactNilFever and coughHaemophilus influenzaeSputum (day 1)Normal (day 2) and normal (day 6)Oseltamivir (5 days), ceftriaxone (5 days), lopinavir/ritonavir (14 days)Alive and discharged (day 22)

CXR = chest radiograph. Parentheses ( ) indicate the day of hospitalization when investigations (chest radiograph and sputum) were carried out, and outcome.

Although uncommon, primary pulmonary coinfection is increasingly being reported with COVID-19, especially with respiratory viruses.15 Nowak et al.2 reported respiratory viral coinfections of 3%. Zhu et al. reported higher rates of coinfection.6 This study tested 257 confirmed COVID-19 patients for respiratory pathogens and found 24 types of respiratory pathogens in 94.2%, with Streptococcus pneumoniae, Klebsiella pneumoniae, and Haemophilus influenzae as the most common pathogens. Most coinfections occurred within 1–4 days of presentation.6 Importantly, isolation of respiratory pathogens in sputum does not distinguish between colonization and clinically relevant infection. Coinfection with Mycobacterium tuberculosis has also been reported.7 Coinfections can result in diagnostic delay and less favorable outcomes. In the Khaddour et al.1 case, the diagnostic delay was due to an investigation protocol driven by limited access to tests for COVID-19. In our setting, we did not routinely test for other respiratory viruses, as there are no specific treatments apart from influenza virus, which was covered by our treatment protocol that included a 5-day course of oseltamivir. However, we did routinely screen for bacterial coinfections on admission. Had we not routinely screened our patients and instead followed a stepwise investigation protocol like Khaddour et al.,1 treatment would have been delayed and outcomes might have been different. Therefore, it is important to consider and screen for the possibility of coinfections with COVID-19.

REFERENCES

  • 1.

    Khaddour K, Sikora A, Tahir N, Nepomuceno D, Huang T, 2020. Case report: the importance of novel coronavirus disease (COVID-19) and coinfection with other respiratory pathogens in the current pandemic. Am J Trop Med Hyg 102: 12081209.

    • Search Google Scholar
    • Export Citation
  • 2.

    Nowak MD, Sordillo EM, Gitman MR, Paniz Mondolfi AE, 2020. Co-infection in SARS-CoV-2 infected patients: where are Influenza virus and rhinovirus/enterovirus? J Med Virol doi: 10.1002/jmv.25953.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wu X et al. 2020. Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis 26: 13241326.

  • 4.

    Chaung J, Chan D, Pada S & Tambyah PA 2020. Coinfection with COVID-19 and coronavirus HKU1 - the critical need for repeat testing if clinically indicated. J Med Virol doi: 10.1002/jmv.25890.

    • Search Google Scholar
    • Export Citation
  • 5.

    Wu D, Lu J, Ma X, Liu Q, Wang D, Gu Y, Li Y, He W, 2020. Coinfection of Influenza virus and severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Pediatr Infect Dis J 39: e79.

    • Search Google Scholar
    • Export Citation
  • 6.

    Zhu X et al. 2020. Co-infection with respiratory pathogens among COVID-2019 cases. Virus Res 285: 198005.

  • 7.

    He G, Wu J, Shi J, Dai J, Gamber M, Jiang X, Sun W, Cai J, 2020. COVID-19 in tuberculosis patients: a report of three cases. J Med Virol doi: 10.1002/jmv.25943.

    • Search Google Scholar
    • Export Citation
  • Figure 1.

    Chest radiographs. (A) Day 3 of hospitalization which was normal and (B) day 5 which showed bilateral consolidations.

  • 1.

    Khaddour K, Sikora A, Tahir N, Nepomuceno D, Huang T, 2020. Case report: the importance of novel coronavirus disease (COVID-19) and coinfection with other respiratory pathogens in the current pandemic. Am J Trop Med Hyg 102: 12081209.

    • Search Google Scholar
    • Export Citation
  • 2.

    Nowak MD, Sordillo EM, Gitman MR, Paniz Mondolfi AE, 2020. Co-infection in SARS-CoV-2 infected patients: where are Influenza virus and rhinovirus/enterovirus? J Med Virol doi: 10.1002/jmv.25953.

    • Search Google Scholar
    • Export Citation
  • 3.

    Wu X et al. 2020. Co-infection with SARS-CoV-2 and influenza A virus in patient with pneumonia, China. Emerg Infect Dis 26: 13241326.

  • 4.

    Chaung J, Chan D, Pada S & Tambyah PA 2020. Coinfection with COVID-19 and coronavirus HKU1 - the critical need for repeat testing if clinically indicated. J Med Virol doi: 10.1002/jmv.25890.

    • Search Google Scholar
    • Export Citation
  • 5.

    Wu D, Lu J, Ma X, Liu Q, Wang D, Gu Y, Li Y, He W, 2020. Coinfection of Influenza virus and severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Pediatr Infect Dis J 39: e79.

    • Search Google Scholar
    • Export Citation
  • 6.

    Zhu X et al. 2020. Co-infection with respiratory pathogens among COVID-2019 cases. Virus Res 285: 198005.

  • 7.

    He G, Wu J, Shi J, Dai J, Gamber M, Jiang X, Sun W, Cai J, 2020. COVID-19 in tuberculosis patients: a report of three cases. J Med Virol doi: 10.1002/jmv.25943.

    • Search Google Scholar
    • Export Citation
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