Francisco Eduardo Dardón-Fierro
Ricard Ferrer
Erika P. Plata-Menchaca- 1Intensive Care Unit, Bellvitge University Hospital, Barcelona, Spain
- 2Intensive Care Unit, Shock, Organ Dysfunction and Resuscitation Group, Vall d'Hebron Research Institute, Vall d'Hebron Hospital Campus, Barcelona, Spain
- 3Intensive Care Unit, Hospital Clinic, Barcelona, Spain
Editorial on the Research Topic
Current evidence on epidemiology and management of infections in critically ill patients
Critically ill patients face heightened risks of infections due to immunosuppression, invasive procedures, and prolonged intensive care unit (ICU) stays. These infections, particularly those caused by multidrug-resistant (MDR) pathogens, remain a leading cause of morbidity and mortality globally, with evolving challenges such as antimicrobial resistance (AMR), diagnostic limitations, and emergent pathogens like SARS-CoV-2 exacerbating outcomes. The COVID-19 pandemic further underscored these vulnerabilities, revealing how overwhelmed healthcare systems and immunosuppressive therapies amplify secondary infections (1–5).
The rationale for this Research Topic (RT) covers the following points:
1. Epidemiological shifts: up to 54% of ICU patients develop nosocomial infections, with bloodstream infections (BSIs), ventilator-associated pneumonia (VAP), and fungal infections driving poor prognoses (1–3, 5).
2. AMR crisis: MDR Gram-negative bacteria (e.g., Pseudomonas aeruginosa, Acinetobacter spp.) and fungi increasingly complicate management, with resistance rates exceeding 60% in some cohorts (2–4).
3. Diagnostic and therapeutic gaps: traditional tools like blood cultures and qSOFA scores lack sensitivity, delaying targeted therapy (6, 7). Simultaneously, balancing antimicrobial stewardship with effective treatment remains contentious (8–11).
The aim of this RT is to address and synthesize recent advances and persisting challenges in infection management for critically ill patients, with three key aims:
1. Analyze evolving epidemiology of ICU-acquired infections, including post-COVID-19 trends.
2. Evaluate innovations in diagnostics (e.g., genomic sequencing) and personalized treatment strategies (e.g., procalcitonin-guided de-escalation, immunomodulation).
3. Highlight actionable frameworks for optimizing antimicrobial use, sepsis management, and infection prevention in resource-limited settings.
As we know, infections in critically ill patients encompass a wide spectrum of clinical conditions, ranging from the early identification of infections associated with a high risk of sepsis, to septic shock and multiple organ dysfunction. These conditions continue to present major challenges to critical care clinicians. The continuous emergence of MDR bacterial infections in the general population of critically ill patients further complicates the diagnosis and management of infections. Some studies have identified MDR organisms in up to 61% of critically ill patients (12). In this regard, two studies examined the prevalence and impact of MDR infections in critically ill patients. In a retrospective study, Zhang et al. analyzed a total of 372 children diagnosed with carbapenem-resistant (CRAB) and carbapenem-sensitive (CSAB) Acinetobacter baumanii at a pediatric intensive care unit (PICU) in a tertiary hospital in China from 2016 to 2021. The primary risk factors associated with CRAB were recent invasive procedures, gastric intubation, prior carbapenem use, severe pneumonia and anemia with hemoglobin values of < 110 g/L. Significant factors associated with overall mortality were septic shock, AST levels >46 U/L, bone marrow aspiration, lymphocyte count < 20% and advanced age. In Brazil, Martins et al. studied 757 patients admitted to the intensive care unit (ICU) of a government university hospital from 2018 to 2020. They found a high prevalence of MDR organisms in critically ill patients (~9.5%), which highlights the significant threat posed by these infections in ICUs.
Early sepsis diagnosis and management are often insufficiently performed. The initial symptoms of sepsis are non-specific, making early diagnosis challenging. The current diagnostic criteria for sepsis screening, such as the quick sequential organ failure assessment (qSOFA) criteria, have limited sensitivity, excluding more than half of sepsis cases. In addition, blood cultures, which are considered the gold standard for infection detection, are negative in around 50% of sepsis cases (7). This diagnostic uncertainty frequently leads to delays in delivering appropriate treatment. In a single-center study, Liu et al. analyzed the prevalence of pneumonia-related bloodstream infections (PRBSI) in a cohort of critically ill patients from 2017 to 2020. Using whole genome sequencing to enhance bacterial identification, they confirmed bloodstream infections (BSI) in 120 patients. PRBSI was documented in 26% of patients. Compared to non-PRBSI patients, those with PRBSI had higher 28-day mortality (81.3 vs. 51.1%), overall mortality (93.8 vs. 64.8%), longer durations of mechanical ventilation (16 vs. 6 days), and longer ICU stays (21 vs. 10 days). These findings underscore the impact of the primary origin of BSI on patient outcomes.
The rapid emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to a global surge of critically ill patients, many presenting with acute respiratory distress syndrome (ARDS), secondary bacterial or fungal infections, and a high risk of thromboembolic complications (13). Effective management of severe COVID-19 cases demanded an increasing understanding of the pathophysiology of the disease, characterized by a dysregulated immune response, hypercoagulability, and direct viral-mediated tissue and endothelial damage (14).
Recognizing these mechanisms was pivotal in guiding therapeutic interventions, including the judicious use of low-dose corticosteroids, antithrombotic treatment, and immunomodulatory agents. Emerging paradigms for optimizing non-invasive respiratory support, mechanical ventilation and prone positioning have been extensively studied (15, 16). Clinical biomarkers were also identified as useful tools for patient classification and prognostication. In a retrospective study, Kaddoura et al. analyzed the prevalence of hypertriglyceridemia in patients admitted to the ICU due to severe SARS-CoV-2 infection. Notably, 82.3% of the patients exhibited hypertriglyceridemia, which was associated with longer recovery times and increased ICU and hospital stays. No significant differences in mortality were observed. Interestingly, 33.8% of patients with hypertriglyceridemia received treatment with fibrates or omega-3 supplements which, despite having beneficial impact in other settings, were associated with a worse prognosis.
Best practice standards on the management of sepsis and septic shock require a holistic approach involving the timely delivery of treatment pillars, such as appropriate antimicrobial therapy, source control, rational fluid resuscitation, and early vasopressor support (17). However, the best strategies for fluid management and vasopressor use remain subjects of ongoing debate. The complexity of sepsis pathophysiology and the heterogeneity of patient responses has recently highlighted the need for more personalized approaches to sepsis diagnosis and treatment.
Ongoing research into early and prognostic biomarkers at the bedside, genetic signatures, and immune responses recognition systems hold promise for improving early diagnosis of sepsis, and tailoring treatments to individual patient phenotypes. The study of adjunctive therapies, such as hemadsorption and immunomodulation has improved in recent years due to better patient selection and predictive enrichment in clinical trials. Some reports suggest these therapies may benefit certain subgroups of patients, although further research is necessary to define their role in sepsis management (12) (Chiscano-Camón et al.). In this context, Chiscano-Camón et al. published a comprehensive review on the current perspective in sepsis management, analyzing the benefits of phenotyping sepsis patients and reviewing the state of the art in standard and adjunctive therapies.
The wide spectrum of presentation and severity of infections in critically ill patients involves new paradigms on the diagnosis and management of organ-specific infections with high-risk of sepsis, and the implementation of early interventions in sepsis and septic shock. Evolving evidence on epidemiology, risk factors, biomarkers, fenotyping and precision medicine is already contributing to improved patient outcomes. Ongoing discoveries are being evaluated to assist clinicians in diagnosing sepsis earlier, before overt irreversible organ dysfunction becomes evident through clinical scores, thereby preventing disease progression and further clinical deterioration.
Author contributions
FD-F: Writing – original draft, Writing – review & editing. RF: Writing – original draft, Writing – review & editing. EP-M: Writing – original draft, Writing – review & editing.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that Gen AI was used in the creation of this manuscript. To assist in the framework of the keypoints to review in this editorial.
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References
1. Bardi T, Pintado V, Gomez-Rojo M, Escudero-Sanchez R, Azzam Lopez A, Diez-Remesal Y, et al. Nosocomial infections associated to COVID-19 in the intensive care unit: clinical characteristics and outcome. Eur J Clin Microbiol Infect Dis. (2021) 40:495–502. doi: 10.1007/s10096-020-04142-w
2. Vincent JL, Sakr Y, Singer M, Martin-Loeches I, Machado FR, Marshall JC, et al. Prevalence and outcomes of infection among patients in intensive care units in 2017. JAMA. (2020) 323:1478–87. doi: 10.1001/jama.2020.2717
3. Gouel-Cheron A, Swihart BJ, Warner S, Mathew L, Strich JR, Mancera A, et al. Epidemiology of ICU-Onset bloodstream infection: prevalence, pathogens, and risk factors among 150,948 ICU patients at 85 US hospitals. Crit Care Med. (2022) 50:1725–36. doi: 10.1097/CCM.0000000000005662
4. Bergmann F, Jorda A, Sollner J, Sawodny R, Kammerer K, List V, et al. Prevalence and clinical implications of bloodstream infections in intensive care patients with or without burn injury: a retrospective cohort study. Eur J Clin Microbiol Infect Dis. (2024) 43:1731–40. doi: 10.1007/s10096-024-04877-w
5. Beck-Friis J, Gisslén M, Nilsson S, Lindblom A, Oras J, Yilmaz A. Intensive care unit-acquired infections more common in patients with COVID-19 than with influenza. Sci Rep. (2024) 14:16655. doi: 10.1038/s41598-024-67733-z
6. Wang C, Xu R, Zeng Y, Zhao Y, Hu X. A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: a meta-analysis. PLoS ONE. (2022) 17:e0266755. doi: 10.1371/journal.pone.0266755
7. Hancock REW, An A, dos Santos CC, Lee AHY. Deciphering sepsis: transforming diagnosis and treatment through systems immunology. Front Sci. (2025) 2:1469417. doi: 10.3389/fsci.2024.1469417
8. BALANCE Investigators for the Canadian Critical Care Trials Group the the Association of Medical Microbiology and Infectious Disease Canada Clinical Research Network the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Australasian Society for Infectious Diseases Clinical Research Network; Daneman N, Rishu A, Pinto R, Rogers BA, Shehabi Y. Antibiotic treatment for 7 versus 14 days in patients with bloodstream infections. N Engl J Med. (2025) 392:1065–78. doi: 10.1056/NEJMoa2404991
9. Westwood M, Ramaekers B, Whiting P, Tomini F, Joore M, Armstrong N, et al. Procalcitonin testing to guide antibiotic therapy for the treatment of sepsis in intensive care settings and for suspected bacterial infection in emergency department settings: a systematic review and cost-effectiveness analysis. Health Technol Assess. (2015) 19:1–236. doi: 10.3310/hta19960
10. de Jong E, van Oers JA, Beishuizen A, Vos P, Vermeijden WJ, Haas LE, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis. (2016) 16:819–27. doi: 10.1016/S1473-3099(16)00053-0
11. Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M, et al. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev. (2017) 10:CD007498. doi: 10.1002/14651858.CD007498.pub3
12. Montrucchio G, Grillo F, Balzani E, Gavanna G, Sales G, Bonetto C, et al. Impact of multidrug-resistant bacteria in a cohort of COVID-19 critically ill patients: data from a prospective observational study conducted in a high- antimicrobial-resistance-prevalence center. J Clin Med. (2025) 14:410. doi: 10.3390/jcm14020410
13. Pfortmueller CA, Spinetti T, Urman RD, Luedi MM, Schefold JC. COVID-19-associated acute respiratory distress syndrome (CARDS): Current knowledge on pathophysiology and ICU treatment—a narrative review. Best Pract Res Clin Anaesthesiol. (2021) 35:351–68. doi: 10.1016/j.bpa.2020.12.011
14. Mangalmurti N, Hunter CA. Cytokine storms: understanding COVID-19. Immunity. (2020) 53:19–25. doi: 10.1016/j.immuni.2020.06.017
15. Gattinoni L, Coppola S, Cressoni M, Busana M, Rossi S, Chiumello D. COVID-19 does not lead to a “typical” acute respiratory distress syndrome. Am J Respir Crit Care Med. (2020) 201:1299–300. doi: 10.1164/rccm.202003-0817LE
16. Li G, Hilgenfeld R, Whitley R, De Clercq E. Therapeutic strategies for COVID-19: progress and lessons learned. Nat Rev Drug Discov. (2023) 22:449–75. doi: 10.1038/s41573-023-00672-y
Keywords: sepsis, COVID-19, communicable diseases, shock, septic, critical care, drug resistance
Citation: Dardón-Fierro FE, Ferrer R and Plata-Menchaca EP (2025) Editorial: Current evidence on epidemiology and management of infections in critically ill patients. Front. Public Health 13:1584879. doi: 10.3389/fpubh.2025.1584879
Received: 27 February 2025; Accepted: 26 May 2025;
Published: 10 June 2025.
Edited and reviewed by: Chiara de Waure, University of Perugia, Italy
Copyright © 2025 Dardón-Fierro, Ferrer and Plata-Menchaca. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Erika P. Plata-Menchaca, ZXJpa2EucGxhdGE4NUBnbWFpbC5jb20=