74. Empiric Antibiotic Therapy and Community-onset Bacterial Co-infection in Patients Hospitalized with COVID-19: A Multi-hospital Cohort Study

Abstract

Background Antibiotic therapy has no known benefit against COVID-19, but is often initiated out of concern for concomitant bacterial infection. We sought to determine how common early empiric antibiotic therapy and community-onset bacterial co-infections are in hospitalized patients with COVID-19. Methods In this multi-center cohort study of hospitalized patients with COVID-19 discharged from 32 Michigan hospitals during the COVID-19 Michigan surge, we describe the use of early empiric antibiotic therapy (within the first two days) and prevalence of community-onset bacterial co-infection. Additionally, we assessed patient and hospital predictors of early empiric antibiotic using poison generalized estimating equation models. Results Between 3/10/2020 and 5/10/2020, data were collected on 951 COVID-19 PCR positive patients. Patient characteristics are described in Table 1. Nearly two thirds (62.4%, 593/951) of COVID-19 positive patients were prescribed early empiric antibiotic therapy, most of which (66.2%, 393/593) was directed at community-acquired pathogens. Across hospitals, the proportion of COVID-19 patients prescribed early empiric antibiotics varied from 40% to 90% (Figure 1). On multivariable analysis, patients were more likely to receive early empiric antibiotic therapy if they were older (adjusted rate ratio [ARR]: 1.01 [1.00–1.01] per year), required respiratory support (e.g., low flow oxygen, ARR: 1.16 [1.04–1.29]), had signs of a bacterial infection (e.g., lobar infiltrate, ARR: 1.17 [1.02–1.34]), or were admitted to a for-profit hospital (ARR: 1.27 [1.11–1.45]); patients admitted later were less likely to receive empiric antibiotics (April vs. March, ARR: 0.72 [0.62–0.84], Table 2). Community-onset bacterial co-infections were identified in 4.5% (43/951) of COVID-19 positive patients (2.4% [23/951] positive blood culture; 1.9% [18/951] positive respiratory culture). Conclusion Despite low prevalence of community-onset bacterial co-infections, patients hospitalized with COVID-19 often received early empiric antibiotic therapy. Given the potential harms from unnecessary antibiotic use, including additional personal protective equipment to administer antibiotics, judicious antibiotic use is key in hospitalized patients with COVID-19. Disclosures Tejal N. Gandhi, MD, Blue Cross Blue Shield of Michigan (Grant/Research Support) Scott A. Flanders, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Blue Cross Blue Shield of Michigan (Research Grant or Support)

Use of antibiotics in COVID-19 ICU patients

“…However, in other studies, the overall proportion of COVID-19 patients with bacterial infections was 6.9% (95% CI 4.3-9.5%) [9]. In our research, the empirical use of antibiotics before admission to the ICU was more frequent (92.3%) than other studies [9,11]. Empirical administration of antibiotics is based on previous experience with bacterial superinfections in influenza or even community acquired pneumonia (CAP) treatment protocols.…”

“…Studies worldwide of COVID-19 patients admitted to hospitals show that a high per cent (up to 94%) were prescribed antibiotics [9]. However, confirmed laboratory bacterial co-infections were low, from 3-14%, depending on whether the COVID-19 cases were treated in regular wards or the ICU [10,11]. The rationale for antibiotic treatment in COVID-19 patients appears to be based on experience with bacterial superinfection in influenza.…”

Risk factors for bacterial infections in patients with moderate to severe COVID‐19: A case‐control study

“…Due to similar clinical phenotype and difficulties in identifying COVID‐19 disease from atypical bacterial pneumonia or nosocomial pneumonia some guidelines advise empirical antibiotics 7 . In a study conducted at 38 hospitals in Michigan 56.6% patients received empirical antibiotics therapy 8 …”

National surveillance of bacterial and fungal coinfection and secondary infection in COVID-19 patients in England: lessons from the first wave

“…There are indications that in response to the COVID-19 epidemic, English hospitals changed their antibiotic prescribing recommendations ( 6 ); a high proportion of COVID-19 patients globally received empirical broad-spectrum antibiotic treatment, including on hospital admission. ( 7 ) The low incidence of detected bacterial/fungal infections in COVID-19 cases may indicate that these strategies were not required. Conversely, this low incidence may have resulted from widespread empirical antimicrobial use, averting bacterial/fungal infections.…”

“…(6) Globally, a high proportion of COVID-19 patients received empirical antibiotic treatment. (7) Whilst this precautionary approach is understandable in the wake of a novel pathogen global pandemic, reductions in antimicrobial stewardship programmes to maximise J o u r n a l P r e -p r o o f appropriate prescribing threaten efforts to curb antibiotic resistance. It is therefore important, particularly given England's second wave coinciding with seasonal increases in respiratory infections, to better characterise the frequency, profile and impact of bacterial/fungal infections in COVID-19 cases.…”