Reviewed by: Cynthia T. Nguyen, PharmD, University of Chicago Medicine and Emily A. Thorell, MD, MSCI University of Utah/Primary Children’s Hospital
Despite data thus far demonstrating low rates of microbiologically-proven bacterial coinfections among COVID-19 inpatients upon admission, many studies report that up to 80% or more of these patients receive antibiotics. Although stewardship in these patients has been difficult, this trio of recent publications may be helpful for stewardship teams as they step up their game during the pandemic.
Karaba and colleagues published a study from the 5 Hopkins Health system hospitals evaluating 1016 adult inpatients with COVID-19 and found a very low rate of bacterial respiratory coinfections (1.2%) during the initial 48 hours of admission. Unique to this study, consensus definitions were developed to define co-infection, which included clinical criteria in addition to microbiologic criteria. Additionally, an adjudication committee ensured consistent application of the criteria across the study population. Based on the consensus definitions, there was only 1 proven bacterial community acquired pneumonia (bCAP) and 11 probable bCAP. Despite this, 69% of patients received empiric antibiotics, although most were stopped within 48 hours. Similar to other reports, this study confirms the low rate of bCAP on admission and high rate of empiric antibiotic use among patients hospitalized with COVID-19.
The high amount of antibiotic use among COVID-19 inpatients, particularly early in the pandemic, may be offset by the overall reduction in antibiotic use secondary to a decrease in healthcare services. Buehrle and colleagues recently evaluated overall antibiotic consumption at VA Pittsburgh (VAPHS) after COVID-19 restrictions were introduced but before the disease was widespread in the region (March – June 2020). Significant increases in antibiotics used for bCAP (e.g, non-antipseudomonal and macrolides) were observed, while antipseudomonal penicillins, non-antipseudomonal cephalosporins, and fluoroquinolones were reduced. There was no change in antipseudomonal cephalosporins, carbapenems, anti-MRSA agents, aminoglycosides, and other agents. These changes in overall antibiotic consumption may be driven by changes in hospital census rather than systematic changes in prescriber behavior. Furthermore, the authors suggest 4 different antimicrobial stewardship strategies that may be useful for clinicians when evaluating COVID-19 patients (see Table 1 in the reference).
Finally, in another retrospective study from the UK, Williams et al evaluated a recommendation to obtain procalcitonin in their COVID-19 guideline using a cutoff ≤0.25ng/ml to withhold antibiotics from patients at low risk for bacterial infection. Of the patients included, 59% had procalcitonin below the cutoff. In that lower risk group, they found fewer defined daily doses of antibiotics overall. Interestingly, they also found that the odds of receiving a carbapenem were 3-fold higher if your procalcitonin was above the cutoff after adjusting for confounders. They did not detect a difference in the rates of infective complications between groups. Mortality was 36% in the higher risk group vs. 28 % in the lower risk group, but this was consistent with data in a national database on mortality risk. They concluded that adherence to a stewardship guideline approach incorporating procalcitonin decreased antibiotic use without causing harm. Hopefully, with more data emerging, stewardship teams will be able to more confidently apply and adapt core ASP strategies in our COVID-19 patients.