key: cord-0892532-r2zn9n1r
authors: Chauhdary, Waqas Ahmed; Chong, Pui Lin; Mani, Babu Ivan; Asli, Rosmonaliza; Momin, Riamiza Natalie; Abdullah, Muhammad Syafiq; Chong, Vui Heng
title: Primary Respiratory Bacterial Coinfections in Patients with COVID-19
date: 2020-06-03
journal: Am J Trop Med Hyg
DOI: 10.4269/ajtmh.20-0498
sha: 415e2cad0e3f4cbfe0272f6d5822edabe3af4cee
doc_id: 892532
cord_uid: r2zn9n1r

Primary Respiratory Bacterial Coinfections in Patients with COVID-19.

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.

Although uncommon, primary pulmonary coinfection is increasingly being reported with COVID-19, especially with respiratory viruses. 1-5 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. 

Case report: the importance of novel coronavirus disease (COVID-19) and coinfection with other respiratory pathogens in the current pandemic

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