Bacterial co-infections and antibiotic prescribing practice in adults with COVID-19: experience from a single hospital cluster

Abstract

Background: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected millions of individuals since December 2019, resulting in significant morbidity and mortality globally. During the 1918 Influenza Pandemic, it was observed that influenza was associated with bacterial co-infections. However, empirical or prophylactic antibiotic use during viral pandemics should be balanced against the associated adverse drug events. Methods: In this retrospective cohort study, we investigated bacterial co-infections in adults with COVID-19 in Hong Kong. Notably, at the time of writing this report, patients with varying disease severities were isolated in hospitals until confirmatory evidence of virological clearance or immunity was available. The study included adults with laboratory-confirmed COVID-19 admitted to a single hospital cluster between 8 January 2020 and 1 May 2020. We obtained data regarding patient demographics, clinical presentations, blood test results, treatment, and outcomes. Bacteriological profiles and risk factors for co-infections were investigated. Antibiotic prescription practices were also reviewed. Results: Of the 147 patients recruited, clinical disease was suspected in 42% ( n = 62) of patients who underwent testing for other respiratory infections. Notably, 35% ( n = 52) of the patients were prescribed empirical antibiotics, predominantly penicillins or cephalosporins. Of these, 35% ( n = 18) received more than one class of antibiotics and 37% ( n = 19) received empirical antibiotics for over 1 week. Overall, 8.2% ( n = 12) of patients developed bacterial co-infections since the detection of COVID-19 until discharge. Methicillin-susceptible Staphylococcus aureus was the most common causative pathogen identified. Although 8.2% ( n = 12) of patients developed hypoxia and required oxygen therapy, no mortality was observed. Multivariate analysis showed that pneumonic changes on chest radiography at the time of admission predicted bacterial co-infections. Conclusion: These findings emphasise the importance of judicious administration of antibiotics throughout the disease course of COVID-19 and highlight the role of antimicrobial stewardship during a pandemic.

Innate Receptor Activation Patterns Involving TLR and NLR Synergisms in COVID-19, ALI/ARDS and Sepsis Cytokine Storms: A Review and Model Making Novel Predictions and Therapeutic Suggestions

“…Since antagonistic TLR and NLR interactions tend to be initiated over time measured by many hours or several days (see Section 2.3), Figure 8 may well explain how the cytokine storm in severe COVID-19 is initiated and Figure 3A the status of the innate system as it attempts to moderate its cytokine production. One final complication is that many severe COVID-19 patients are treated with multiple antibiotics [201][202][203][204][205][206][207][208][209][210][211][212], which may further modify the expression of bacterially activated TLR and NOD1/NOD2.…”

The Complexity of Co-Infections in the Era of COVID-19

“…Empiric, potent, or prolonged antibiotic therapy increases risk for nosocomial infection. In addition, the COVID-19 context has been significantly associated with increasing antibiotic use [119][120][121]. The presence of a potentially complex infection along with the use of either steroids or immunomodulatory treatments otherwise increases the potential for secondary bacterial infections.…”

“…The COVID-19 experience on this theme is considerable to date. Empiric antibiotic use is common among these patients [76,[119][120][121]131]. The frequency of such use may decline with experience [76].…”

“…Macrolide and beta-lactam antimicrobial use dominate in this context [121]. There is a low incidence of secondary bacterial infections in many studies [74,76,120,121,[131][132][133][134]. The lower incidence is most common among the very early phases of infection as would be anticipated [76,134].…”

COVID-19: Questions of Antimicrobial Resistance

“…Nonetheless, it has been observed that a significant proportion of antimicrobial was prescribed imprudently where microbial or bacterial infection possibility were improbable 53 . Multivariate analysis revealed that at the hospital's point of admission, pneumonic changes in chest radiograph were suggestive of bacterial co-infection among the COVID-19 patients and demands prudent use of antimicrobials 54 . Similarly, multiple research studies revealed that only those COVID-19 patients with radiologically identified bilateral pulmonary infection required antimicrobials therapy [55][56][57][58][59][60] .…”