Co-infections in people with COVID-19: a systematic review and meta-analysis

J Infect. 2020 Aug;81(2):266-275. doi: 10.1016/j.jinf.2020.05.046. Epub 2020 May 27.


Objectives: In previous influenza pandemics, bacterial co-infections have been a major cause of mortality. We aimed to evaluate the burden of co-infections in patients with COVID-19.

Methods: We systematically searched Embase, Medline, Cochrane Library, LILACS and CINAHL for eligible studies published from 1 January 2020 to 17 April 2020. We included patients of all ages, in all settings. The main outcome was the proportion of patients with a bacterial, fungal or viral co-infection. .

Results: Thirty studies including 3834 patients were included. Overall, 7% of hospitalised COVID-19 patients had a bacterial co-infection (95% CI 3-12%, n=2183, I2=92·2%). A higher proportion of ICU patients had bacterial co-infections than patients in mixed ward/ICU settings (14%, 95% CI 5-26, I2=74·7% versus 4%, 95% CI 1-9, I2= 91·7%). The commonest bacteria were Mycoplasma pneumonia, Pseudomonas aeruginosa and Haemophilus influenzae. The pooled proportion with a viral co-infection was 3% (95% CI 1-6, n=1014, I2=62·3%), with Respiratory Syncytial Virus and influenza A the commonest. Three studies reported fungal co-infections.

Conclusions: A low proportion of COVID-19 patients have a bacterial co-infection; less than in previous influenza pandemics. These findings do not support the routine use of antibiotics in the management of confirmed COVID-19 infection.

Keywords: COVID-19; Coinfection; Coronavirus; Meta-Analysis.

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Bacterial Infections / complications
  • Bacterial Infections / epidemiology
  • Bacterial Infections / virology*
  • Betacoronavirus
  • COVID-19
  • Coinfection / epidemiology
  • Coinfection / microbiology*
  • Coinfection / virology*
  • Coronavirus Infections / complications
  • Coronavirus Infections / epidemiology
  • Coronavirus Infections / virology*
  • Humans
  • Mycoses / complications
  • Mycoses / epidemiology
  • Mycoses / virology
  • Pandemics
  • Pneumonia, Viral / complications
  • Pneumonia, Viral / epidemiology
  • Pneumonia, Viral / virology*
  • SARS-CoV-2
  • Virus Diseases / complications
  • Virus Diseases / epidemiology
  • Virus Diseases / microbiology