Low rate of bacterial co-infection in patients with COVID-19

Adler, Hugh; Ball, Robert L.; Fisher, Michael; Mortimer, Kalani; Vardhan, Madhur

doi:10.1016/s2666-5247(20)30036-7

Cited by 73 publications

(80 citation statements)

References 7 publications

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“…Using a consensus clinical definition, we found that only 1.1% of patients had a probable bacterial respiratory co-infection (ie, had clinical and radiographic criteria consistent with bCAP and responded to antibiotic therapy, but did not have a microbiologic diagnosis). The proportion of patients with proven respiratory co-infection in our study was lower than in published studies, in which the percentage with proven respiratory co-infection has ranged from 3.1% to 5% [ 10 , 11 , 17 ]. This difference may be explained by the consensus definitions we employed, by the timing of the outbreak in our geographic area (spring vs winter in Europe and China) when non-SARS-CoV-2 respiratory viruses were circulating infrequently, or by the population affected (unknown history of pneumococcal vaccination between populations in different studies).…”

Section: Discussioncontrasting

confidence: 89%

“…The IDSA/American Thoracic Society CAP guidelines suggest empiric initial antibacterial treatment for those with influenza due to the relatively high rates of bacterial co-infection [ 5 ]. However, the low prevalence of bacterial co-infection shown here, as well as in other studies, would suggest that empiric initial antibiotics are not needed, and in fact are not recommended in World Health Organization recommendations [ 10 , 11 , 17 , 29 ]. The time period of the study does not cover the peak of respiratory viral season, limiting its generalizability and possibly leading to underestimation of respiratory viral co-infection.…”

Section: Discussionmentioning

confidence: 80%

See 1 more Smart Citation

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

Karaba

Jones

Helsel

et al. 2020

Open Forum Infectious Diseases

109

100

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Background Bacterial infections may complicate viral pneumonias. Recent reports suggest that bacterial co-infection at time of presentation is uncommon in coronavirus disease 2019 (COVID-19); however, estimates were based on microbiology tests alone. We sought to develop and apply consensus definitions, incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19. Methods A total of 1016 adult patients admitted to 5 hospitals in the Johns Hopkins Health System between March 1, 2020, and May 31, 2020, with COVID-19 were evaluated. Adjudication of co-infection using definitions developed by a multidisciplinary team for this study was performed. Both respiratory and common nonrespiratory co-infections were assessed. The definition of bacterial community-acquired pneumonia (bCAP) included proven (clinical, laboratory, and radiographic criteria plus microbiologic diagnosis), probable (clinical, laboratory, and radiographic criteria without microbiologic diagnosis), and possible (not all clinical, laboratory, and radiographic criteria met) categories. Clinical characteristics and antimicrobial use were assessed in the context of the consensus definitions. Results Bacterial respiratory co-infections were infrequent (1.2%); 1 patient had proven bCAP, and 11 (1.1%) had probable bCAP. Two patients (0.2%) had viral respiratory co-infections. Although 69% of patients received antibiotics for pneumonia, the majority were stopped within 48 hours in patients with possible or no evidence of bCAP. The most common nonrespiratory infection was urinary tract infection (present in 3% of the cohort). Conclusions Using multidisciplinary consensus definitions, proven or probable bCAP was uncommon in adults hospitalized due to COVID-19, as were other nonrespiratory bacterial infections. Empiric antibiotic use was high, highlighting the need to enhance antibiotic stewardship in the treatment of viral pneumonias.

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Section: Discussioncontrasting

confidence: 89%

Section: Discussionmentioning

confidence: 80%

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

Karaba

Jones

Helsel

et al. 2020

Open Forum Infectious Diseases

109

100

View full text Add to dashboard Cite

show abstract

“…The rate of concurrent bacterial LRTI in this cohort was 6%, which is reflective of those reported elsewhere. 1 , 2 However, antimicrobial therapy was continued after the return of a positive SARS-CoV-2 PCR result and absence of microbiological evidence of bacterial infection in the majority of patients, with median duration of antimicrobial therapy of 7 days. It is advised that IV-to-oral switch is performed within 72 h in the absence of ongoing indication for parenteral therapy.…”

Section: Discussionmentioning

confidence: 99%

“…Concurrent bacterial or fungal infection rates in COVID-19 infection appear to be low. 1 , 2 The rates are much lower than in patients admitted with influenza 3 and also appear to be lower than for other coronaviruses. 4 However, COVID-19 may be indistinguishable from bacterial respiratory tract infections at the time of presentation.…”

Section: Introductionmentioning

confidence: 90%

Bacterial pneumonia coinfection and antimicrobial therapy duration in SARS-CoV-2 (COVID-19) infection

Townsend

Hughes

Kerr

et al. 2020

JAC-Antimicrobial Resistance

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Background Bacterial respiratory coinfection in the setting of SARS-CoV-2 infection remains poorly described. A description of coinfection and antimicrobial usage is needed to guide ongoing antimicrobial stewardship. Objectives To assess the rate of empirical antimicrobial treatment in COVID-19 cases, assess the rate and methods of microbiological sampling, assess the rate of bacterial respiratory coinfections and evaluate the factors associated with antimicrobial therapy in this cohort. Methods Inpatients with positive SARS-CoV-2 PCR were recruited. Antibiotic prescription, choice and duration were recorded. Taking of microbiological samples (sputum culture, blood culture, urinary antigens) and culture positivity rate was also recorded. Linear regression was performed to determine factors associated with prolonged antimicrobial administration. Results A total of 117 patients were recruited; 84 (72%) were prescribed antimicrobial therapy for lower respiratory tract infections. Respiratory pathogens were identified in seven (6%) patients. The median duration of antimicrobial therapy was 7 days. C-reactive protein level, oxygen requirement and positive cultures were associated with prolonged duration of therapy. Conclusions The rate of bacterial coinfection in SARS-CoV-2 is low. Despite this, prolonged courses of antimicrobial therapy were prescribed in our cohort. We recommend active antimicrobial stewardship in COVID-19 cases to ensure appropriate antimicrobial prescribing.

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“…Use of immunosuppressants such as tocilizumab and dexamethasone [14,15] to combat COVID-19 cytokine storm also contributes to empiric antibacterial and antifungal therapy [16] with concerns about potential development of antimicrobial resistance (AMR) [17,18]. Some preliminary data suggest bacterial and fungal superinfection may be less common in COVID-19 pneumonia than in in uenza [19]. However, superinfecting or colonizing microorganisms have not been well-described for the former.…”

Section: Introductionmentioning

confidence: 99%

Bacterial and Fungal Growth in Sputum Cultures from 165 COVID-19 Pneumonia Patients Requiring Intubation: Evidence for Antimicrobial Resistance Development and Analysis of Risk Factors

Liu

Yaron

Piraino

et al. 2020

Preprint

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Background: Coronavirus SARS-CoV-2 causes COVID-19 illness which can progress to severe pneumonia. Empiric antibacterials are often employed though frequency of bacterial superinfection is debated and concerns raised about selection of bacterial antimicrobial resistance. We evaluated sputum bacterial and fungal growth from 165 intubated COVID-19 pneumonia patients. Objectives were to determine frequency of culture positivity, risk factors for and outcomes of positive cultures, and timing of antimicrobial resistance development. Methods: Retrospective reviews were conducted of COVID-19 pneumonia patients requiring intubation admitted to a 1,058-bed four community hospital system on the east coast United States, March 1 to May 1, 2020. Length of stay (LOS) was expressed as mean (standard deviation); 95% confidence interval (95% CI) was computed for overall mortality rate using the exact binomial method, and overall mortality was compared across each level of a potential risk factor using a Chi-Square Test of Independence. All tests were two-sided, and significance level was set to 0.05.Results: Average patient age was 68.7 years. Eighty-three patients (50.3% of total) originated from home, 10 from group homes (6.1% of total), and 72 from nursing facilities (43.6% of total). Mortality was 62.4%, highest for nursing home residents (80.6%). Findings from 253 sputum cultures overall were evaluated and did not suggest acute bacterial or fungal infection in 89 (54%) of 165 individuals sampled within 24 hours of intubation. Cultures > one week following intubation did grow potential pathogens in 72 (64.9%) of 111 cases with 70.8% consistent with late pneumonia and 29.2% suggesting colonization. Twelve (10.8% of total) of these late post-intubation cultures revealed worsened antimicrobial resistance predominantly in Pseudomonas, Enterobacter, or Staphylococcus aureus.Conclusions: In severe COVID-19 pneumonia, a radiographic ground glass interstitial pattern and lack of purulent sputum suggest antibacterials are not needed. Discontinuation of empiric antibacterials should be considered after 48 hours in absence of sputum to culture or results reported "without growth" or "normal flora." Continuing longterm hospitalisation and antibiotics are associated with sputum cultures reflective of hospital-acquired microbes and increasing antimicrobial resistance.Trial registration: Not applicable as this was a retrospective chart review study without interventional arm.

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Low rate of bacterial co-infection in patients with COVID-19

Cited by 73 publications

References 7 publications

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

Bacterial pneumonia coinfection and antimicrobial therapy duration in SARS-CoV-2 (COVID-19) infection

Bacterial and Fungal Growth in Sputum Cultures from 165 COVID-19 Pneumonia Patients Requiring Intubation: Evidence for Antimicrobial Resistance Development and Analysis of Risk Factors

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