Increased Use of Antibiotics in the Intensive Care Unit During Coronavirus Disease (COVID-19) Pandemic in a Brazilian Hospital

Abstract

Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic.Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment.Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat.Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial’s use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Impact of the COVID-19 Pandemic on Inpatient Antibiotic Consumption in Switzerland

“…This contradictory finding could be due to differences in ICU occupancy; while hospitals in Catalonia experienced a large increase in bed-days in the ICUs in 2020, the number of ICU bed-days in Switzerland was comparable to that in 2019 [ 17 ]. In contrast, similar results for the ICU as in Switzerland were also observed in other studies [ 10 , 20 , 21 ]. Considering only the consumption of broad-spectrum antibiotics, we consistently found an increase for DID (+10.2%), as well as for DDD/100 bed-days (+12.3%), as was found in other studies [ 11 , 22 , 23 , 24 ].…”

Bacterial Coinfection and Antibiotic Resistance Profiles among Hospitalised COVID-19 Patients

“…A. baumannii strains recovered from sputum of ICU COVID-19 patients were more resistant against ceftazidime, ceftriaxone, gentamicin, and trimethoprim/sulfamethoxazole compared to isolates from non-ICU patients. This observation and the emergence of completely resistant strains in ICU specimens can be attributed to overuse of antibiotics in the ICU during the pandemic, leading to an extensive selection pressure for resistance and increased dissemination of multi-drug resistant organisms [ 49 ]. Moreover, strains of A. baumannii isolated from the blood of both COVID-19 groups showed resistance to all tested antibiotics.…”

Is the Pendulum of Antimicrobial Drug Resistance Swinging Back after COVID-19?

“…It is difficult to understand the causes of the increase in bacterial species that are multiresistant to antibiotics in patients with COVID-19 admitted to ICU, but we would like to raise attention to the following points: (i) both the intrahospital transmission of these bacteria and a nonoptimal antibiotic stewardship may have exerted an important role in raising antimicrobial resistance rates [ 17 , 18 ]; (ii) COVID-19-dedicated ICU appeared an important hotspot for the spread of MDR pathogens, probably for some specific peculiarities that should be addressed: patient overcrowding, insufficient personnel, suboptimal adherence to standard precautions due to the use of individual protective equipment, insufficient rapid isolation of patients with MDR colonization at admission [ 4 ], and these factors may have concurred to determine several outbreaks that occurred as reported also by other authors [ 19 , 20 ]; (iii) a cross-transmission of MDR bacteria may have occurred through importation from other hospitals since “ Mater Domini ” teaching hospital is the reference center of Calabria Region for care of patients with severe respiratory infections; (iv) despite poor evidence [ 7 ], antibiotic therapy is often prescribed in COVID-19 patients both in in-hospital and in outpatient settings, thus creating a collateral damage by limiting available antibiotic choices [ 21 , 22 ]. Although restriction in prescribing antibiotic therapies is important to avoid the selection of MDR bacteria, the severe clinical conditions of patients admitted to ICU and immunodeficiency associated both with COVID-19 by itself and with immunomodulating therapies prescribed make it difficult to apply this rule in most patients [ 2 ].…”