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Afnan J Alshrefy,1 Rawaa N Alwohaibi,1 Shahad A Alhazzaa,1 Reema A Almaimoni,1 Latifah I AlMusailet,1 Shaya Y AlQahtani,2 Mohammed S Alshahrani3 1College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Eastern Province, Saudi Arabia; 2Department of Internal Medicine and Critical Care Medicine, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Eastern Province, Saudi Arabia; 3Emergency and Critical Care Departments, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Eastern Province, Saudi ArabiaCorrespondence: Mohammed S Alshahrani, Emergency and Critical Care Departments, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Khobar, Eastern Province, 34219, Saudi Arabia, Tel +966556966663, Fax +966138966770, Email Msshahrani@iau.edu.saPurpose: Secondary infections have been observed among coronavirus disease 2019 (COVID-19) patients, especially in the intensive care unit (ICU) setting, which is associated with worse clinical outcomes. The current study aimed to investigate the incidence, common pathogens, and outcome of bacterial and fungal secondary infections among ICU patients with COVID-19.Methods: A retrospective chart review of all patients admitted to the ICU at King Fahd Hospital of the University in Saudi Arabia. All adult patients aged ≥ 18 admitted in the ICU for ≥ 48 hours with positive COVID-19 reverse transcription-polymerase chain reaction test during the period between March 2020 till September 2021 were included.Results: Out of 314 critically ill patients, 133 (42.4%) developed secondary infections. The incidence of secondary bacterial infection was 32.5% with Pseudomonas aeruginosa (n = 34), Acinetobacter baumannii (n = 33), and Klebsiella pneumoniae (n = 17) being the predominant pathogens, while secondary fungal infection was 25.2% mainly caused by Candida albicans (n = 43). Invasive mechanical ventilation was significantly associated with the development of secondary bacterial infections (odds ratio [OR] = 17.702, 95% confidence interval [CI] 7.842– 39.961, p < 0.001) and secondary fungal infections (OR = 12.914, 95% CI 5.406– 30.849, p < 0.001). Mortality among patients with secondary infections was 69.2% (n = 92). Secondary infections were associated with longer hospital and ICU stays with a median of 25 days (interquartile range [IQR] 17– 42) and 19 days (IQR 13– 32), respectively.Conclusion: Bacterial and fungal secondary infections are common among COVID-19 patients admitted to the ICU with a predominance of gram-negative bacteria and Candida species. The development of secondary infections was significantly associated with invasive mechanical ventilation. Poor clinical outcomes have been observed, demonstrated with a prolonged hospital and ICU stays and higher mortality.Keywords: COVID-19, intensive care unit, secondary infection, bacterial, fungal