Risk of Venous Thromboembolism in Infectious Diseases: A Literature Review
Abstract
1. Introduction
2. Risk of VTE in Hospitalized Patients with Infection and in Community Setting
3. Risk of VTE in COVID-19 Patients
4. Risk of VTE in Human Immunodeficiency Virus (HIV)-Infected Patients
5. Risk of VTE in Tuberculosis (TB)
6. Risk of VTE in HCV-Infected Patients
7. Risk of VTE in CMV-Infected Patients
8. Risk of VTE in Patients with Other Infections
9. Thromboprophylaxis of Infection-Related VTE
10. Discussion
11. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
Appendix A
1st Author, Year Ref | Aim | Design | Population | Main Results | Notes |
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Cohoon, 2018 [19] | To evaluate the occurrence of infection (overall and specific infection) in people with deep vein thrombosis and pulmonary embolism. | Population-based Case control study. | Pts with deep vein thrombosis and/or pulmonary embolism over 35-year period in a US population of 144,248 individuals. | 513/1303 (39.4%) cases and 189/1494 (12.7%) controls had an infection in the previous 92 days. Unadjusted OR = 4.5; 95% CI: 3.6–5.5 (p < 0.0001). | In a multivariate analysis adjusting for other common venous thromboembolism risk factors, any infection (pneumonia, UTI, intrabdominal infections, blood stream infections) increased the odds of venous thromboembolism (OR 2.4; 95% CI: 1.8–3.2; p < 0.0001). |
Alikhan, 2004 [2] | To evaluate different types of acute medical illness and predefined factors (chronic heart and respiratory failure, age, previous VTE, and cancer) as risk factors for VTE. | Logistic regression analysis from a RCT. | Hospitalized pts with acute medical illness (heart failure, respiratory failure, infection, rheumatic disorder, inflammatory bowel disease). | The primary univariate analysis showed that the presence of an acute infectious disease, age older than 75 years, cancer, and a history of VTE were statistically significantly associated with an increased VTE risk. Multiple logistic regression analysis indicated that these factors were independently associated with VTE. | Multivariate analysis shows that acute infection was an independent risk factor for VTE: OR, 1.74 (95% CIs, 1.12–2.75), p = 0.02. |
Smeeth, 2006 [8] | To investigate whether acute infections increase the risk of VTE. | Records from general practices who had registered pts with the UK’s Health Improvement Network database between 1987 and 2004. | A self-controlled case-series method to study the risk of first DVT (n = 7278) and first PE (n = 3755) after acute respiratory and UTI. | The risks of DVT and PE were significantly raised, and were highest in the first two weeks, after UTI. The incidence ratio for DVT was 2.10 (95% CI 1.56–2.82), and that for PE 2.11 (1.38–3.23). The risk gradually fell over the subsequent months, returning to the baseline value after 1 year. The risk of DVT was also higher after respiratory tract infection. | Acute infections are associated with a transient increased risk of VTE events in a community setting. Our results confirm that infection should be added to the list of precipitants for VTE and suggest a causal relation. |
Levine, 2008 [22] | Venous and arterial TE in severe sepsis. | A retrospective analysis of data from 3 RCTs. | A total of 2649 pts in ICU with known or suspected infection and sepsis-associated acute organ dysfunction. | 84 of 2649 pts (3.2%; 95% Cl, 2.5–3.9%) developed at least one TE event over 28 days. Nearly 3/4 of episodes were atheroembolic (n = 62); 25% involved the deep venous system (n = 25). Ischemic stroke (n = 30) and venous TE (n = 25) each occurred in about 1% of pts. | Clinically manifest TE occurred in about 3% of severe sepsis pts treated in the ICU. Arterial TE may be more common than previously recognized. |
Clayton, 2010 [23] | Recent respiratory infections and risk of TE. | Case–control study through a general practice database. | All cases aged ≥18 years of first-time diagnosis of DVT or PE were identified together with single-matched controls from a primary care general practice database. | There were 457/11,557 (4.0%) DVT cases with respiratory infection in the year before the index date (73 in the preceding month) compared with 262/11,557 (2.3%) controls (24 in the preceding month). There was an increased risk of DVT in the month following infection [adjusted odds ratio (OR) = 2.64, 95% confidence interval (95% CI) 1.62–4.29] which persisted up to a year. | There are strong associations between recent respiratory infection and VTE. |
Rothberg, 2011 [3] | Risk factor model to predict venous TE in hospitalized medical pts. | Retrospective cohort study. | Pts admitted to 374 US hospitals with a primary diagnosis of pneumonia, heart failure, COPD, stroke, and UTI. | Of 242,738 pts, 612 (0.25%) pts fulfilled our criteria for VTE during hospitalization, and an additional 440 (0.18%) were readmitted for VTE within 30 days (overall incidence of 0.43%). In the multivariable model, age, sex, and additional risk factors were associated with VTE. The strongest risk factors were inherited thrombophilia (OR 4.00), length of stay ≥6 days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. | The risk of symptomatic VTE in general medical pts is low. |
Schmidt, 2011 [24] | To evaluate whether hospital-diagnosed infections or infections treated in the community increase the risk of VTE. | Population-based case– control study in northern Denmark using medical databases. | We identified all pts with a first hospital-diagnosed VTE during the period 1999–2009 (n = 15,009). For each case, we selected 10 controls from the general population matched for age, gender, and county of residence (n = 150,074). We used the regional prescription database to identify all antibiotic prescriptions filled by cases and controls 1 year before their index date. | Respiratory tract, urinary tract, skin, intra-abdominal, and bacteraemic infections diagnosed in hospital or treated in the community were associated with a greater than equal to twofold increased VTE risk: 3.3 (95% CI: 2.9–3.8) and 2.6 (95% CI: 2.5–2.8), respectively. | Compared with individuals without infection during the year before VTE, the IRR for VTE within the first 3 months after infection was 12.5 (95% CIs: 11.3–13.9) for pts with hospital-diagnosed infection and 4.0 (95% CI: 3.8–4.1) for pts treated with antibiotics in the community. Adjustment for VTE risk factors reduced these IRRs to 3.3 (95% CI: 2.9–3.8) and 2.6 (95% CI: 2.5–2.8), respectively. |
Del Principe, 2013 [25] | To determine: (1) the risk factors associated with CVC-related thrombosis (CRT) and their frequency in a homogeneous population of pts with AML; (2) the impact of an antithrombotic prophylaxis using LMWH on CRT occurrence. | Retrospectively cohort of 71 consecutive AML pts. | Hospitalized pts with acute myeloid leukemia (AML). | Occurrence of CRT was significantly associated with CVC-exit site infections (14/19, p = 0.01) and sepsis (16/19, p = 0.005) with no difference between LMWH and no-LMWH group. | In multivariate analysis, both CVC-exit site infections and sepsis were confirmed to be independent risk factors for CRT development. |
Dalager-Pederson, 2014 [9] | To evaluate the risk of VTE within one year of CAB in comparison to that in matched controls. | Danish cohort study. A regression analyses with adjustment for confounding factors was used to compare the risk of VTE in bacteraemia pts and controls. | 4213 adult CAB pts who had positive blood cultures drawn on the day of hospital admission, 20,084 matched hospitalised controls admitted for other acute medical illness, and 41,121 matched controls from the general population. | Among CAB pts, 1.1% experienced VTE within 90 days of admission and 0.5% during 91–365 days after admission. The adjusted 90-day odds ratio (OR) for VTE was 1.9 (95% CI 1.4–2.7) compared with hospitalised controls, and 23.4 (95% CI 12.9–42.6) compared with population controls. | The risk of VTE is substantially increased within 90 days after community-acquired bacteraemia when compared to hospitalised controls and population controls. However, the absolute risk of VTE following CAB is low. |
Barr, 2014 [26] | To establish risk of VTE in pts treated for bacterial infection in the community with outpatient parenteral antimicrobial therapy. | Retrospective cohort. | Out-pts with bacterial infection. | VTE incidence of 2/780 (0.26%, 95% CI: 0.03–0.92%). | The study found a low incidence of VTE in OPAT pts and does not support routine application of inpatient VTE prophylaxis algorithms to pts treated for infection in the community. |
Frasson, 2015 [27] | RIETE Investigators. Infection as cause of immobility and occurrence of VTE analysis of 1635 medical cases from a registry. | Data were collected from the worldwide RIETE registry (47,390 pts), including pts with symptomatic objectively confirmed VTE and followed-up for at least 3 months. | Subgroup of non-surgical pts with infection leading to immobility and reported. As risk factor/cause for VTE by the attending physicians. Pts with infection were compared to those with dementia causing immobility (dementia, differently from infection, is not known as relevant risk factor for VTE). | Compared with pts immobilized due to dementia, pts with infection had a shorter duration of immobilization prior to VTE (less than 4 weeks in 94.2 vs. 25.9% of cases). During the 3-month follow-up, VTE pts with infection versus those with dementia had a lower rate of fatal bleeding (0.5 vs. 1.1%; p < 0.05) or fatal PE (1.7 vs. 3.5%; p < 0.01). Pts with respiratory tract infections had more likely PE as initial VTE presentation than other types of infection (62.3 vs. 37.7%; p < 0.001). Significantly more pts with pneumonia than those with other respiratory infections had received VTE prophylaxis (50.2 vs. 30.6%; p < 0.001). | Infection seems to contribute to the pathogenesis of VTE by accelerating the effects of immobility. |
Cowan, 2017 [28] | To explore the relationship between hospitalization with infection and short-term VTE risk. | A case-crossover design and conditional logistic regression were used. | Hospitalized infections among VTE cases with corresponding control periods 1 year and 2 years prior. Data collected from prospective ARIC cohort. | Of the 845 total VTE cases, 75 had a hospitalization with an infection in the 90 days preceding the VTE event. | Hospitalized infection is a trigger of VTE. There is an association between hospitalization with infection and subsequent short-term VTE risk that exceeds the known association between hospitalization and VTE. |
Grimnes, 2017 [20] | To investigate the impact of hospitalization with acute infection on the VTE-risk in pts with and without concomitant immobilization, and to explore the differential impact RTI and UTI tract infections on the risk of DVT and PE. | A population-based crossover study. Hospitalizations and VTE-triggers were registered during the 90 days before a VTE (hazard period) and in four preceding 90-day control periods. | VTE-pts (n = 707) recruited from a general population. | Acute infection was registered in 267 (37.8%) of the hazard periods and in 107 (3.8%) of the control periods, corresponding to a high VTE-risk after infection (OR 24.2, 95% CI 17.2–34.0), which was attenuated to a 15-fold increased after adjustment for immobilization. The risk was 20-fold increased after infection without concomitant immobilization, 73-fold increased after immobilization without infection, and 141-fold increased with the two combined. | Hospitalization with infection is a strong VTE trigger also in non-immobilized pts. Infection and immobilization had a synergistic effect on the VTE-risk. |
Carpenter, 2019 [29] | NS results in hypercoagulability and increased risk of infection. Furthermore, infection increases the risk of VTE. Our objective was to determine the prevalence of infection, VTE, and the associated outcomes among a cohort of hospitalized children with NS. | Retrospective cohort. | A cohort of hospitalized children with NS. | 730 hospitalizations occurred among 370 children with NS. 148 children (40%) had ≥1 infection (211 episodes) and 11 (3%) had VTE. | Hospitalized children with NS have high rates of infection. Presence of VTE was associated with infection. Both were associated with longer hospitalizations and ICU stays. |
Eck, 2021 [30] | ICU pts | A pooled analysis of two prospective cohort studies. | 2208 pts admitted to ICU. | The prevalence of any VTE during 3 months before ICU admission was 3.6%. Out of 2166 pts, in ICU, 47 (2.2%; 95% CI 1.6–2.9%) developed PE-LDVT and 38 pts (1.8%; 95% CI 1.2–2.4%) developed NLDVT. Renal replacement therapy (OR 3.5: 95% CI 1.4–8.6), respiratory failure (OR 2.0; 95% CI 1.1–3.8), and previous VTE (OR 3.6; 95% CI 1.7–7.7) were associated with PE-LDVT. Central venous catheters (OR 5.4; 95% CI 1.7–17.8) and infection (OR 2.2; 95% CI 1.1–4.3) were associated with NLDVT. | Thrombotic events are common in critically ill pts, both before and after ICU admittance. Development of PE-LDVT but not NLDVT was associated with increased mortality. |
Smilowitz, 2021 [31] | Risk of thrombotic events after respiratory infection requiring hospitalization. | US nationwide database 2012-14. Pts admitted with asthma or cellulitis served as comparators. Readmissions for acute myocardial infarction (MI) and VTE were evaluated at 30 to 180 days. | Pts discharged after a respiratory infection. | Among 5,271,068 pts, 0.56% and 0.78% were readmitted within 30-days with MI and VTE, respectively. Relative to asthma and cellulitis, respiratory infection was associated with a greater age and sex-adjusted hazard of 30-day readmission for MI (adjusted HR [aHR] 1.48 [95% CI 1.42–1.54] vs. asthma; aHR 1.36 [95% CI 1.31–1.41] vs. cellulitis) and VTE (aHR 1.28 [95% CI 1.24–1.33] vs. asthma; aHR 1.26, [95% CI 1.22–1.30] vs. cellulitis). | Hospitalization for respiratory infection was associated with increased risks of thrombosis that were highest in the first 30-days after discharge and declined over time. |
Angriman, 2022 [3] | To determine whether surviving a first sepsis hospitalization is associated with long-term cardiovascular events. | Population-based matched cohort study. | Septic adult pts survivors of a first sepsis hospitalization were matched to adult survivors of a non-sepsis hospitalization using hard-matching and propensity score methods. | Sepsis survivors experienced an increased hazard of major cardiovascular events compared to non-sepsis survivors (HR 1.30; 95% CI 1.27–1.32), which was more pronounced in younger (<40 yrs) pts (HR 1.66; 95% CI 1.36–2.02). | Sepsis survivors also faced an increased hazard of VTE (HR 1.61; 95% CI 1.55–1.67) and all-cause death (HR 1.26; 95% CI 1.25–1.27). |
Pisani, 2022 [32] | To evaluate VTE risk in the pre-COVID-19 era in a large ICU database. | A database for ICU pts. | Consecutive pneumonia pts admitted to the ICU. | The 30-day cumulative incidence of VTE was 7%. Mortality was 20.6% among pts with VTE and 19.2% among those without VTE. | VTE risk in ICU pts with pneumonia was high and decreased with thromboprophylaxis. The diagnosis of VTE did not substantially affect the risk of death. |
1st Author, Year Ref | Clinical Setting | No. of Studies | Outcomes | Results | Main Conclusions |
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Birkeland, 2020 [34] | Hospitalized pts. | 14 observational studies (1677 pts). | VTE incidence; d-dimer level. | VTE incidence was 26.9% (95% CI 20.8–33.1). D-dimer was higher for the VTE cohort (5.62 [SD 0.9] vs. 1.43 [SD 0.6]; p < 0.001. | Despite the utilization of background anticoagulation, VTE incidence was high. Odds of VTE were higher in the ICU (OR 6.38, 95% CI 3.67–11.11; p < 0.001) but lower with anticoagulation (OR 0.58, 95% CI 0.36–0.92; p = 0.02). |
Di Minno, 2020 [12] | Hospitalized pts with different severity of COVID-19 (from 0 to 100% ICU admission). | 20 observational studies (1988 pts). | VTE, DVT, PE incidence. | Mean prevalence (MP) of VTE was 31.3% (95% CI: 24.3–39.2%); MP of DVT was 19.8% (95% CI: 10.5–34.0%); MP of PE was 18.9% (95% CI: 14.4–24.3%). | The rate of TE complications in COVID-19 pts is definitely high, particularly in pts admitted to ICUs. Rate of TE complications remain high also among pts under antithrombotic prophylaxis. |
Lu, 2020 [35] | Hospitalised COVID-19 pts with various severity of infection | 25 observational studies (20 on VTE incidence and 5 on the relationship between anticoagulation and mortality). | To determine the incidence of VTE and evaluate the role of anticoagulation in pts with COVID-19. | Pooled incidence rates of VTE, PE, and DVT were 21% (95% CI 15–27%), 15% (95% CI 10–20%), and 27% (95% CI 19–36%), respectively. | The incidence of VTE among hospitalised COVID-19 pts was high. Rates of VTE were higher among pts admitted to the ICU; antithrombotic therapy was not associated with a lower mortality risk (RR = 0.86, 95% CI, 0.69–1.09). |
Porfidia, 2020 [36] | Hospitalized pts with COVID-19. | 30 observational studies (3487 pts). | Incidence of VTE in pts with COVID-19. | Incidence of VTE was 26% (95% PI, 6–66%). PE with or without DVT occurred in 12% of pts (95% PI, 2–46%) and DVT alone in 14% (95% PI, 1–75%). In pts admitted to ICU, VTE occurred in 24% (95% PI, 5–66%), PE in 19% (95% PI, 6–47%), and DVT alone in 7% (95% PI, 0–69%). Corresponding values in general wards were respectively 9% (95% PI, 0–94%), 4% (95% PI, 0–100%), and 7% (95% CI, 1–49%). | VTE represents a frequent complication in hospitalized COVID-19 pts and often occurs as PE. |
Tu, 2020 [37] | COVID-19 pts with CVT. | 9 studies and 14 COVID-19 pts with CVT were studied. | Incidence of CVT. | A significant proportion of pts had raised D-dimer (75.0%) and CRP levels (50.0%). Two pts reported presence of antiphospholipid antibodies. Most pts received anticoagulation (91.7%) while overall mortality rate was 45.5%. | Whilst infrequently reported, CVT has been found to occur in pts with COVID-19 infection. The unusually high mortality rate warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated in these settings. |
Zhang, 2020 [38] | Hospitalized COVID-19 pts. | 17 retrospective cohort studies (1913 pts). | VTE (DVT, PE) occurrence. | The pooled incidence of VTE was 25% (95% CI, 19–31%), with a significant difference between the incidence of PE (19%; 95% CI, 13–25%) and DVT (7%; 95% CI, 4–10%). | VTE incidence was 25% in hospitalized COVID-19 pts. Higher incidence of VTE was observed in COVID-19 pts with a severe condition or with a low rate of pharmacologic thromboprophylaxis. |
Kunutsor, 2020 [39] | Hospitalised pts. | 35 observational cohort studies (9249 pts). | VTE, PE, DVT. | The pooled incidence was 18.4% (12.0–25.7) for VTE (n = 19 studies), 13.5% (8.4–19.5) for PE (n = 22 studies) and 11.8% (7.1–17.4) for DVT (n = 18 studies). | There is a high incidence of TE complications in hospitalized COVID-19 pts (from 7.2 to 40.8%), which appears to be driven by VTE disease. These TE complications are remarkably high in COVID-19 infection despite the use of thromboprophylaxis. The most frequently diagnosed venous TE complication in the overall population is PE; the incidence of TE complications is substantially higher in severe COVID-19 disease compared to the overall population, with a higher incidence of DVT than PE. |
Sridharan, 2020 [40] | Hospitalized pts. with different disease severity. | 11 observational studies (1478 pts). | VTE events. | Pooled rate of major VTE was 12.5% in hospitalized pts. and 17.2% in ICU pts. When therapeutic anticoagulation dosing was compared with prophylactic anticoagulation, the pooled OR of VTE was 0.33 (95% CIs 0.14–0.75; p = 0.008) suggesting statistical significance with therapeutic dosing of anticoagulation for primary prevention of VTE in all hospitalized pts. | Major VTE events, especially pulmonary embolism, seem to be high in COVID-19 pts admitted to the ICU. Therapeutic anticoagulation dosing seems to significantly benefit the odds of preventing any VTE when compared with prophylactic dosing in all hospitalized pts. |
Chi, 2020 [41] | Preliminary evidence indicates that prophylactic-dose thromboprophylaxis may be inadequate to control the increased risk of VTE in pts hospitalized for COVID-19. | 11 cohort studies. | Frequency of VTE and death among COVID-19 pts who received thromboprophylaxis on hospitalization. The endpoints included VTE, PE, DVT, and mortality. | Among hospitalized COVID-19 pts, 23.9% (95% CI, 16.2% to 33.7%;) developed VTE despite anticoagulation. PE and DVT were detected in 11.6% (95% CI, 7.5% to 17.5%) and 11.9% (95% CI, 6.3% to 21.3%;) of pts, respectively. Pts in the ICU had a higher risk of VTE (30.4%; 95% CI, 19.6% to 43.9%) than those in the ward (13.0%; 95% CI, 5.9% to 26.3%). The mortality was estimated at 21.3% (95% CI, 17.0% to 26.4%). | COVID-19 pts who developed VTE had higher D-dimer levels than those who did not develop VTE (mean difference, 2.05 µg/mL; 95% CI, 0.30 to 3.80 µg/mL; p = 0.02). Prominent elevation of D-dimer may be associated with VTE development and can be used to identify high-risk subset. |
Hasan, 2020 [42] | COVID-19 admitted to ICU. | 12 studies. | VTE. | The pooled prevalence of VTE among ICU pts receiving prophylactic or therapeutic anticoagulation across all studies was 31% (95% CI 20–43%). Subgroup pooled analysis limited to studies reporting prophylactic anticoagulation alone and mixed (therapeutic and prophylactic anticoagulation) reported pooled prevalences of VTE of 38% (95% CI 10–70%) and 27% (95% CI 17–40%), respectively. | With a high prevalence of thromboprophylaxis failure among COVID-19 pts admitted to ICU, individualised rather than protocolised VTE thromboprophylaxis would appear prudent at interim. |
Srivastava, 2021 [43] | COVID-19 pts | 13 cohort studies (6648 pts). | Association between VTE and diseases severity. | Pts with PE and DVT are at increased risk of being admitted to ICU (RR: 2.21; 95% CI: 1.86–2.61; p < 0.001) and (RR: 2.69; 95% CI: 2.37–3.06; p < 0.001), respectively. | This study highlights the need to consider measures for reducing thromboembolism risk amongst COVID-19 pts. |
Gabbai-Armelin, 2021 [13] | Hospitalized pts with different severity of COVID-19. | 20 studies (case–control, cohort) were included in the qualitative analysis, and 6 in the meta-analysis. | Prognostic factors for TE. | Hypertension and diabetes were the comorbidities more frequently associated with thrombolytic events. Significant results were found regarding D-dimer (p < 0.0001) and age (p = 0.0202) for TE. | Pts older than 60 years, with hypertension, diabetes, and D-dimer values above 3.17 µg/mL can be considered prognostic factors for developing TE due to COVID-19. |
Liu, 2021 [44] | Hospitalized pts. | 26 studies (18 retrospective, 6 prospective observational, and 2 cross-sectional) for a total of 4382 pts. | Incidence of VTE, DVT, PE. | The total incidence of VTE was 28.3% (95% CI, 21.6–35.4%), with an incidence of 38.0% (95% CI, 29.1–47.4%) and 17.2% (95% CI, 11.4–23.8%) among those with severe and general COVID-19, respectively. The total incidence of DVT of the lower extremities was 18.3% (95% CI, 10.8–27.2%), ranging from 22.1% (95% CI, 11.0–35.5%) and 12.8% (95% CI, 5.0–23.3%) in those with severe and general COVID-19, respectively. The total incidence of PE was 17.6% (95% CI, 12.3–23.5%), with a rate of 21.7% (95% CI, 14.8–29.3%) in severe cases and 12.5% (95% CI, 6.1–23.5%) in general cases. | The occurrence of VTE, DVT, and PE has been substantial among hospitalized pts with COVID-19, especially among those with severe COVID-19. Pts with severe COVID-19 and VTE had significantly greater mortality compared with similar pts without VTE. An increased D-dimer level might be an indicator of the occurrence of VTE in pts with COVID-19. |
Mai, 2021 [45] | Hospitalized pts with or without COVID-19. With similar disease severity. Within each study, groups were comparable in terms of ICU admission rates, sex, age, and methods for VTE diagnosis. | 7 observational studies (41,768 pts). | To compare the rate of VTE between COVID-19 and non-COVID-19 cohorts with similar disease severity. | The overall risk of VTE (RR 1.18; 95%CI 0.79–1.77; p = 0.42), PE (RR 1.25; 95% CI 0.77–2.03; p = 0.36; I2 = 52%) and deep venous thrombosis (RR 0.92; 95%CI 0.52–1.65; p = 0.78) did not significantly differ between COVID-19 and non-COVID-19 cohorts. However, subgroup analyses suggested an increased risk of VTE amongst COVID-19 versus non COVID-19 cohorts when only pts hospitalized within the ICU were considered (RR 3.10; 95% CI 1.54–6.23), which was not observed in cohorts of predominantly non-ICU pts (RR 0.95; 95%CI 0.81–1.11). | There was no signal for a difference in VTE in COVID-19 cohorts compared to non-COVID-19 cohorts, except for the subgroup of pts hospitalized in the ICU. |
Mansory, 2021 [46] | COVID-19 pts hospitalized in ICU or in non-ICU wards. | 91 observational cohort studies (35,017 pts). 35 studies included ICU pts only, 23 studies had non-ICU pts only, and 33 studies included both ICU and non-ICU pts. | To evaluate the epidemiology of VTE, DVT, PE in hospitalized ICU and non-ICU pts. | The overall frequency of VTE in all pts, ICU and non-ICU, was 12.8% (95% CI: 11.10–14.60), 24.1% (95% CI: 20.07–28.28), and 7.7% (95% CI: 5.95–9.70), respectively. PE occurred in 8.5% (95% CI: 6.91–10.20), and proximal DVT occurred in 8.2% (95% CI: 6.67–9.87) of all hospitalized pts. The relative risk of VTE associated with ICU admission was 2.99 (95% CI: 2.301–3.887, p < 0.001). | This study confirmed a high risk of VTE in hospitalized COVID-19 pts, especially those admitted to the ICU. Nevertheless, sensitivity analysis suggests that previously reported frequencies of VTE in COVID-19 might have been overestimated. |
Tufano, 2021 [47] | COVID-19 and other pulmonary infection cohorts, in particular H1N1, and in an ICU setting. | 12 cohort studies (prospective and retrospective, +1 autoptic study) (1,013,495 pts). | To compare the occurrence of VTE, PE, and DVT between COVID-19 and other pulmonary infection cohorts, in particular H1N1, and in an ICU setting. | We observed a high RD between COVID-19 and non-COVID-19 pts for VTE (6% more risk as compared with non-COVID-19) and PE, in particular in pts admitted to the ICU. (11% more risk in ICU) | It is not completely clear why some infections such as COVID-19 have a strong influence on coagulation and are associated with thrombosis, while in others this effect is limited. |
Wu, 2021 [48] | Critically ill COVID-19 pts. | 19 observational studies with 1599 pts. | Prevalence of VTE, DVT, and PE. | Prevalence of VTE, DVT, and PE was 28.4% [95% CI: 20.0–36.8%], 25.6% (95% CI: 17.8–33.4%), and 16.4% (95% CI: 10.1–22.7%), respectively. Limited to studies, in which all pts received routine prophylactic anticoagulation, the prevalence for VTE, DVT, and PE was 30.1% (95% CI: 19.4–40.8%), 27.2% (95% CI: 16.5–37.9%), and 18.3% (95% CI: 9.8–26.7%), respectively. | Critically ill pts with COVID-19 have a high prevalence of VTE, despite the use of present routine prophylactic anticoagulation. |
Kollias, 2021 [49] | Hospitalized pts with different severity of illness. | 17 studies (3973 pts.) reported PE, and 32 studies (2552 pts.) reported DVT. | Prevalence of VTE, DVT, and PE. | Pooled PE prevalence of 32% (95% CI: 25, 40%) and DVT prevalence of 27% (95% CI: 21, 34%) were reported. | Meta-regression analysis showed that the prevalence of VTE was higher across studies with a higher percentage of ICU pts and higher study population mean D-dimer values. Hospitalized pts with severe COVID-19 are at high VTE risk despite prophylactic anticoagulation. |
Gallastegui, 2021 [50] | Hospitalized pts with different severity of illness. | 57 studies. | Incidence of PE. | PE incidence among all hospitalized COVID19 pts was 7.1% (95% CI: 5.2%, 9.1%). Pts admitted to ICUs had higher PE incidence (13.7%; 95% CI: 8.0%, 20.6%). | PE incidences among hospitalized COVID19 pts are much lower than has been previously postulated based on smaller, often biased study reports. |
Jenner, 2021 [51] | ICU-treated pts with COVID-19. | 28 studies (2928 pts). | Prevalence of VTE, DVT, and PE. | Thrombotic complications occurred in 34% of ICU-managed pts, with DVT reported in 16.1% and PE in 12.6% of pts. | Studies adopting systematic screening for venous thrombosis with duplex ultrasound reported a significantly higher incidence of DVT compared to those relying on clinical suspicion (56.3% vs. 11.0%, p < 0.001). |
Zuin, 2021 [52] | COVID-19 pts after hospital discharge. | 11 studies (18,949 pts). | Incidence of VTE (DVT, PE). | The cumulative post-discharge rate of VTE in COVID-19 pts ranged between 0.2 and 14.8%. The pooled incidence is 1.8% (95% CI: 0.8–4.1). | Meta-regression analysis revealed that the post-discharge incidence of VTE events was directly affected by age (p = 0.03) and male gender (p = 0.04) and inversely correlated with the length of follow-up period (p = 0.012). Conversely, no associations were identified using postdischarge thromboprophylaxis (p = 0.20), cancer (p = 0.14), VTE history (p = 0.82), ICU admission (p = 0.55), and mean length of hospitalization (p = 0.68). |
Lobbes, 2021 [14] | COVID-19 in ICU. | 21 studies (5296 pts). | To evaluate risk factors for VTE. | A moderate-certainty evidence was found for an association between VTE and the D-dimer peak (OR 5.83, 95% CI: 3.18–10.70), and length of hospitalization (OR 7.09, 95% CI: 3.41–14.73) and intubation (OR 2.61, 95% CI: 1.94–3.51), and a low-certainty evidence for an association between VTE and CRP (OR 1.83, 95% CI: 1.32–2.53), D-dimer (OR 4.58, 95% CI: 2.52–8.50), troponin T (OR 8.64, 95% CI: 3.25–22.97), and the requirement for inotropic drugs (OR 1.67, 95% CI: 1.15–2.43). | Traditional VTE risk factors (i.e., history of cancer, previous VTE events, obesity) were not found to be associated to VTE in COVID-19. Anticoagulation was not associated with a decreased VTE risk. VTE RF in severe COVID-19 correspond to individual illness severity and to inflammatory and coagulation parameters. |
Mansory, 2022 [53] | In ambulatory and discharged COVID-19 pts. | 16 cohort studies (11 retrospective and 5 prospective). 102,779 pts. | To evaluate the epidemiology of VTE and arterial thrombosis events in ambulatory and postdischarge COVID-19 pts. | The overall proportion of VTE events in all pts (ambulatory and post-discharge) was 0.80% (95% CI: 0.44–1.28), 0.28% (95% CI: 0.07–0.64), and 1.16% (95% CI: 0.69–1.74), respectively. Arterial events occurred in 0.75% (95% CI: 0.27–1.47) of all pts, 1.45% (95% CI: 1.10–1.86) of post-discharge pts, and 0.23% (95% CI: 0.019–0.66) of ambulatory pts. | This study found a low risk of venous and arterial thrombi in ambulatory and postdischarge COVID-19 pts, with a higher risk in post-discharge pts compared with ambulatory pts. This suggests that regular universal thromboprophylaxis in these patient populations is probably not necessary. |
Candeloro, 2023 [54] | Hospitalized pts with COVID-19. | 36 trials (28 retrospective cohorts, 5 prospective cohorts, and 3 RCTs), 100,949 pts. | To evaluate the frequency of ATEs, AMI, AIS, ALI, or other ATE. | The pooled ATE frequency was 2.0% (95% PI, 0.4–9.6%). The pooled ATE frequency for AMI, AIS, ALI, and other ATE was 0.8% (95% PI, 0.1–8.1%), 0.9% (95% PI, 0.3–2.9%), 0.2% (95% PI, 0.0–4.2%), and 0.5% (95% PI, 0.1–3.0%), respectively. | There was a non-negligible proportion of ATE in pts. hospitalized for COVID-19. The results are similar to those found in hospitalized pts with influenza or with non-COVID viral pneumonia. |
Dutch COVID and Thrombosis Coalition, 2021 [60] | 947 pts hospitalized in 8 Dutch hospitals during the first and second COVID-19 waves. | 1 multicenter cohort study. | Incidence of thrombotic complications and overall mortality in COVID-19 pts admitted to 8 Dutch hospitals between 1 September and 30 November 2020. | 144 pts died (15%). The adjusted cumulative incidence of all thrombotic complications after 10, 20 and 30 days was 12% (95% CI: 9.8–15%), 16% (13–19%) and 21% (17–25%), respectively. Pts characteristics between the first and second wave were comparable. The adjusted HR for overall mortality in the second wave versus the first wave was 0.53 (95% CI: 0.41–0.70). The adjusted HR for any thrombotic complication in the second versus the first wave was 0.89 (95% CI: 0.65–1.2). | Mortality was reduced by 47% in the second wave, but the thrombotic complication rate remained high, and comparable to the first wave. Careful attention to provision of adequate thromboprophylaxis is invariably warranted. |
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Viral RF | Drugs RF | Host RF |
---|---|---|
CD4 cells count | Megestrol acetate | Age |
IRIS | HAART | Hypercoagulable state |
Opportunistic infections:
|
| |
HIV viral load | Endothelial dysfunction | |
HIV-associated malignancies | Miscellaneous factors of haemostasis | |
Antiphospholipid antibodies | ||
|
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Pati, I.; Masiello, F.; Piccinini, V.; De Fulvio, L.; Massari, M.S.; De Angelis, V.; Cruciani, M. Risk of Venous Thromboembolism in Infectious Diseases: A Literature Review. Pathogens 2025, 14, 816. https://doi.org/10.3390/pathogens14080816
Pati I, Masiello F, Piccinini V, De Fulvio L, Massari MS, De Angelis V, Cruciani M. Risk of Venous Thromboembolism in Infectious Diseases: A Literature Review. Pathogens. 2025; 14(8):816. https://doi.org/10.3390/pathogens14080816
Chicago/Turabian StylePati, Ilaria, Francesca Masiello, Vanessa Piccinini, Lucia De Fulvio, Maria Simona Massari, Vincenzo De Angelis, and Mario Cruciani. 2025. "Risk of Venous Thromboembolism in Infectious Diseases: A Literature Review" Pathogens 14, no. 8: 816. https://doi.org/10.3390/pathogens14080816
APA StylePati, I., Masiello, F., Piccinini, V., De Fulvio, L., Massari, M. S., De Angelis, V., & Cruciani, M. (2025). Risk of Venous Thromboembolism in Infectious Diseases: A Literature Review. Pathogens, 14(8), 816. https://doi.org/10.3390/pathogens14080816