Association of Extended Steroid Treatment With Bloodstream Infection in Critically Ill Patients With COVID-19: A National, Multicenter, Propensity Score-Matched Study

Background: The impact of steroid treatment on mortality outcomes in patients with coronavirus disease 2019 (COVID-19) has been widely demonstrated, while its effect on secondary infections, such as bloodstream infections (BSIs), is controversial. Recent studies have reported the survival benefits of using steroids for a standard duration compared to extended use, though their impact on the risk of BSIs remains debated. This study investigated whether extended steroid use is associated with the risk of BSIs and mortality in critically ill patients with COVID-19. Methods: This national multicenter retrospective study conducted at 22 university-affiliated hospitals evaluated the effect of steroid treatment duration in hospitalized patients with COVID-19 treated with more than high-flow nasal cannula therapy. Patients were divided into two groups according to the duration of corticosteroid treatment: extended (> 10 days) and standard (<= 10 days). Propensity score matching was performed by adjusting for covariates. Baseline characteristics and clinical outcomes were compared between the two groups. Results: Among 1,114 patients, 378 with a hospital length of stay (LOS) exceeding 10 days were included. Each group of the propensity score-matched cohort had 189 patients, with no significant differences in demographic characteristics between the two groups, except for the incidence of BSIs (extended group vs. standard group, 49.7% vs. 36.0%, P = 0.043). After adjusting for confounding factors, extended use of steroids remained significantly associated with BSIs (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.25-4.04; P = 0.007). The use of a mechanical ventilator, extracorporeal membrane oxygenation, continuous renal replacement therapy, and a longer hospital LOS were associated with BSIs. In-hospital mortality was associated with an older age, higher body mass index, higher sequential organ failure assessment score at admission, and the presence of a BSI (OR, 2.47; 95% CI, 1.50-4.05; P < 0.001). Kaplan-Meier survival analysis demonstrated no significant difference in in-hospital mortality between the extended and standard groups. Conclusion: Extended steroid therapy was significantly associated with a higher incidence of BSIs in critically ill patients with COVID-19.