Antimicrobial utilization in COVID-19 patients for suspected coinfection or superinfection

AHS’ COVID-19 Scientific Advisory Group (SAG) recently investigated the latest evidence from around the world pertaining to a key topic: Antimicrobial utilization in COVID-19 patients for suspected coinfection or superinfection

There was little evidence found describing bacterial and fungal co-pathogens associated with COVID-19. Although approximately 8% of COVID-19 positive patients appear to have co-pathogens identified across series, no ‘signal’ bacterial co-pathogens have been identified.

Despite the lack of microbiologic documentation around initial co-infection at presentation and later superinfections, the literature indicates significant and widespread antibiotic use in hospitalized COVID-19 patients across various countries. However, antibiotics have not been proven to improve clinical outcomes; in fact, the stewardship literature suggest that unnecessary antibiotic use is linked with increased risk to patients, including Clostridioides difficile colitis risk.

Recommendations

1. Antimicrobial stewardship programs can play a key role in guiding the appropriate use of antimicrobials in patients with COVID-19. Empiric antibiotic therapy is generally not required for a classic viral pneumonia presentation unless the differential diagnosis includes community acquired pneumonia (CAP), or initial co-infection is strongly suspected based on a thorough clinical assessment. Microbiologic specimens should be collected to confirm co-diagnosis and inform treatment.
2. After microbiologic specimens have been obtained, COVID-19 patients with secondary bacterial infection could be considered for empiric therapy for hospital acquired pneumonia (HAP) or ventilator associated pneumonia (VAP).
   • Empiric antimicrobial therapy recommendations can be found in AHS Bugs & Drugs and SpectrumMD.
3. Empiric antimicrobial therapy should be re-assessed at day 3 and then with evolution of laboratory and culture results and the patient’s clinical status, for opportunities to discontinue, de-escalate, or transition to targeted antimicrobial therapy.
4. If there is evidence of bacterial CAP or HAP where cultures cannot be procured or culture results are felt to be unreliable, guideline supported duration of therapy includes a 5 day course of antibiotics for CAP and a 7 day course for HAP.

To see the complete list of Rapid Response Reports, please check the COVID-19 Scientific Advisory Group website. New reports and updates appear here on a daily basis.