Joedhistira Bayu Firmansyah, Musofa Rusli , Juniastuti, Ratna Septyawati

Profiles of Deceased Patients with Coronavirus Disease 2019 (COVID-19) and Multidrug-Resistant Bacterial Coinfections at an Indonesian Tertiary Hospital

Introduction

Profiles of deceased patients with coronavirus disease 2019 (covid-19) and multidrug-resistant bacterial coinfections at an indonesian tertiary hospital. Analyze profiles of deceased COVID-19 patients with multidrug-resistant bacterial coinfections at an Indonesian hospital. Understand demographics, microbiology, and resistance patterns to improve surveillance and stewardship.

Abstract

Introduction: Antibiotic use in coronavirus disease 2019 (COVID-19) patients reached 70% during the pandemic, potentially inducing the invasion of multidrug-resistant organisms (MDROs). This study analyzed patients who died from COVID-19 with MDRO coinfections at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Methods: We conducted a retrospective descriptive study of 120 deceased COVID-19 inpatients from January to December 2021. The inclusion criteria required: (1) positive MDRO cultures from ≥2 specimens, and (2) resistance to ≥1 agent across ≥3 antimicrobial categories. Patients with incomplete records or no antibiotic therapy were excluded. The data were presented using descriptive statistics to characterize patient demographics, microbiological profiles, and antimicrobial resistance patterns. Results: The patients were predominantly male (60%), aged 41–80 years (78.33%), and hospitalized for 8–30 days (53.44%). The microbiological examinations revealed blood cultures as the main specimen source (43.10%), followed by sputum (27.59%), urine (19.40%), pus (7.33%), and cerebrospinal fluid (2.59%). The prevalent isolates varied by specimen type: coagulase-negative staphylococci (51%) in blood, Pseudomonas spp. in pus (17.65%), Klebsiella spp. in sputum (26.69%), and Escherichia coli in urine (37.78%). The cerebrospinal fluid cultures showed an equal distribution of Gram-negative bacilli, Gram-positive bacilli, and Gram-positive cocci (33.33% each). Conclusion: This study characterizes the profiles of fatal COVID-19 cases with MDRO coinfections, demonstrating a predominance of older male patients with prolonged hospitalization. The identified resistance patterns and pathogen distribution, notably coagulase-negative staphylococci in blood, highlight the importance of improved infection surveillance and antibiotic stewardship to minimize the risk of coinfection in the future. Highlights: 1. While existing studies have examined multidrug-resistant organism (MDRO) coinfections in COVID-19 globally, this work offers a valuable standalone characterization of a high-risk subgroup in Indonesia, where resistance patterns arising from antimicrobial use during the pandemic created unique clinical challenges. 2. This study provides comprehensive data on the mortality of COVID-19 patients with MDRO coinfections at Dr. Soetomo General Academic Hospital, Surabaya, Indonesia, enhancing medical personnel's awareness of MDRO bacterial transmission and informing improvements in antibiotic stewardship programs within hospitals.

Review

This study provides a valuable descriptive analysis of deceased COVID-19 patients experiencing multidrug-resistant organism (MDRO) coinfections at a tertiary hospital in Indonesia. The research effectively characterizes a high-risk patient subgroup, revealing that these fatal cases predominantly involved older male patients with prolonged hospital stays. The detailed microbiological profiles, including the specific pathogens identified in various specimen types (e.g., coagulase-negative staphylococci in blood, *Klebsiella spp.* in sputum, *E. coli* in urine), are particularly insightful. This granular data is crucial for understanding the local epidemiological landscape of antimicrobial resistance, which is explicitly highlighted as a unique challenge arising from widespread antibiotic use during the pandemic. The study's focus on a specific regional context fills an important gap in global literature, enhancing awareness among local medical personnel and providing foundational data to inform targeted antibiotic stewardship programs. While the study offers essential insights, its retrospective descriptive design inherently limits the ability to infer causality or broader generalizability. Being a single-center study, the findings, though valuable for Dr. Soetomo General Academic Hospital, may not be directly transferable to other healthcare settings within Indonesia or internationally without further validation. The abstract highlights the inclusion criterion of "positive MDRO cultures from ≥2 specimens," which, while ensuring robust MDRO identification, might lead to an underestimation of the true incidence of MDRO coinfections if some patients only had a single positive culture. Furthermore, while the conclusion points to the importance of improved infection surveillance and antibiotic stewardship, the abstract does not elaborate on specific strategies or detailed recommendations that could arise directly from the observed resistance patterns beyond the general call to action. In conclusion, this research makes a significant contribution by providing the first detailed characterization of fatal COVID-19 cases with MDRO coinfections in an Indonesian tertiary care setting. The identified profiles and pathogen distribution are critical for guiding empirical antibiotic therapy decisions and improving infection control practices within the hospital. The study strongly reinforces the urgent need for enhanced infection surveillance and robust antibiotic stewardship programs to mitigate the risk of MDRO development, especially in populations vulnerable to severe viral infections. Future research could build upon these findings by employing prospective designs, incorporating control groups, or conducting multicenter studies to assess the generalizability of these profiles and evaluate the impact of specific stewardship interventions.

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