Antimicrobial Management of Respiratory Infections in Severe Acute Respiratory Syndrome Coronavirus 2 Patients: Clinical and Antimicrobial Stewardship Programs Conundrums

Abstract

The role of empirical and even directed antimicrobial management of patients hospitalized with SARS- CoV-2 infection is problematic; antibiotics are used frequently among these patients whether to treat confirmed or suspected co-infection or simply symptoms. In the rapidly changing clinical landscape of SARS- CoV-2 there is minimal guidance for selecting appropriate treatment versus non-antimicrobial treatment, and clinicians are pressed to make daily decisions under the stress of absence of data while watching patients deteriorate. We review current data and patterns of antimicrobial use and the potential approach for antimicrobial stewardship in the context of SARS- CoV-2.

Prevalence of Empiric Antibacterial Therapy, Community-Acquired Bacterial Superinfection, and Antibiotic-Associated Adverse Reactions among Patients with COVID-19 Pneumonia Admitted in Makati Medical Center from March 2020 to March 2021

“…On the other hand, like any other viral illness, a COVID-19 patient also has a risk to develop a concomitant bacterial infection. Data on bacterial coinfections among COVID-19 patients are quite limited and usually range from 3.0 – 30.0% [ 5 6 ] Similar to other studies, it was noted that many patients with COVID-19 infection were often started with early empiric antibiotic therapy despite the lack of evidence of a bacterial superinfection [ 6 7 ]. This was particularly notable during the early part of the pandemic wherein the disease was quite new and no established treatment was present.…”

“…This was particularly notable during the early part of the pandemic wherein the disease was quite new and no established treatment was present. The increased use of unnecessary antibiotic therapy in purely COVID-19 infection can pose the development of antibiotic-associated adverse effects such as the emergence of resistant bacterial strains and other drug reactions [ 7 ].…”

Potential Roles for Probiotics in the Treatment of COVID-19 Patients and Prevention of Complications Associated with Increased Antibiotic Use

“…High rates of mortality (16–46%) due to sepsis, respiratory failure, or ventilator-associated pneumonia (VAP) have been observed in COVID-19 inpatients [ 7 , 8 , 9 ]. Most (58–95%) COVID-19 inpatients have been placed on empiric antibiotics to prevent ventilator-associated pneumonia (VAP) and secondary infections, creating an inherent challenge for antimicrobial stewardship programs (ASP) [ 7 , 10 ]. The justification for the high use of empiric antibiotics has been questioned based on the low rate of co-infections at admission (3–6%), the low rate of secondary bacterial and fungal infections developing during hospitalization (4–14%), and concerns about the complications of the overuse of antibiotics [ 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ].…”

“…The justification for the high use of empiric antibiotics has been questioned based on the low rate of co-infections at admission (3–6%), the low rate of secondary bacterial and fungal infections developing during hospitalization (4–14%), and concerns about the complications of the overuse of antibiotics [ 7 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Patients admitted with COVID-19 continue to receive empiric antibiotics (58–95%), despite concerns of antibiotic overuse [ 10 ].…”

“…Two potential strategies suggested to reduce antibiotic complications in COVID-19 patients have included antibiotic stewardship programs to reduce the overuse of empiric antibiotics and the use of specific probiotics to prevent AAD or CDI [ 10 , 20 ]. Probiotics have been previously shown to effectively reduce AAD and CDI among other types of diseases, due to multiple mechanisms of action found in some probiotic strains, including destruction of pathogenic toxins, inference with pathogen attachment to host cells, and the ability to act as an immune regulator among other mechanisms [ 21 , 22 , 23 , 24 ].…”