Antimicrobial Use in COVID-19 Patients

Since the SARS-CoV-2/COVID-19 pandemic, we have been learning at a rapid pace. From testing to immunity and even isolation precautions, this has been a “build the bridge as you walk across” situation. One piece to this is also patient care and the medical management of those hospitalized with COVID-19.

Increasingly, there have been concerns about antimicrobial stewardship during COVID-19 response, as the “use everything but the kitchen sink” approach is easily deployed during novel and emergent times. While COVID-19 is a novel disease, antimicrobial resistance is not. The Centers for Disease Control and Prevention (CDC) reported that in the United States alone, someone gets a resistant infection every 11 seconds and every 15 minutes, someone dies as a result of their antimicrobial-resistant infection.

For those reported infections, there are 3 million cases in the U.S. each year and 48,000 related deaths. Prevention efforts to combat antimicrobial resistance are critical but when faced with a pandemic, can be challenging. In addition to use of antimicrobial therapy in COVID-19 patients, should we be worried that there will be subsequent bacterial co-infections? A research team from the University of Michigan, sought to understand the empiric use of antimicrobial therapy in hospitalized COVID-19 patients, but also the prevalence of bacterial co-infections once they were discharged and out in the community.

The research team randomly sampled a cohort of 1,705 Michigan patients across 38 hospitals from March to June of this year. “Data were collected on early (prescribed within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial co-infections (positive culture or diagnostic test within 3 days).”

When they analyzed the results, researchers found that 56.6% of those COVID-19 hospitalized patients were prescribed empiric antibacterial therapy. Thankfully, only 3.5% had a confirmed community-onset bacterial infection. More worrisome, use of empiric antibacterials ranged from 27%-84% and those patients of advanced age were more likely to receive them.

They also found that those with a lower body mass index, experiencing a lobar infiltrate, had more severe illness, or were admitted to a for-profit hospital, were also more likely to receive early empiric antibacterial therapies. Moreover, the authors noted that “Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs. in April [85.2%, 628/737], P<.001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs. March) decreased.”

While these findings show that community-onset bacterial co-infections were relatively low, the concerning use of early empiric antibacterial therapies is worrisome. Even more concerning in that the testing time was quite short and should have allowed for better antimicrobial stewardship. More attention to both issues — testing turnaround times and antimicrobial stewardship – can help improve patient outcomes and reduce the use of unnecessary antibiotics.

Moreover, this can help reduce unnecessary isolation precautions and even reduce the risk of infections like Clostridioides difficile. Simply put, it behooves us to improve diagnostics in sensitivity/specificity, but also speed for not only COVID-19 identification, but also the prevention of early empiric antimicrobial use. As COVID-19 is something we’ll likely be dealing with for the near future, implementing patient safety approaches to medical management will be increasingly important.