In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication.

ICU-AI were common and were significantly associated with use of corticosteroids.

Data were available from 4,994 patients.

Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage.

ICU-AI developed in 2,715 (54%).

The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved multi-drug resistant organisms (MDRO).

Patients developing infections in ICU had greater antimicrobial exposure than those without such infections.

Incident density (ICU-AI per 1,000 ICU days) was in considerable excess of reports from pre-pandemic surveillance.

Corticosteroid use was heterogenous between ICUs.

In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI.

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