Experts give lessons on antibiotic management from COVID-19

A panel of experts from the Society for Healthcare Epidemiology of America (SHEA) released a statement last week on ways to improve antibiotic use and management during pandemics and infectious disease outbreaks.

The statement, published in Infection control and hospital epidemiology, addresses widespread inappropriate antibiotic use during the COVID-19 pandemic. The peak of unnecessary antibiotic use occurred in the early stages of the pandemic, when hospitals were flooded with critically ill patients, diagnostic tests were unavailable or took several days for results to come back, treatments were not available, and health care providers wanted to do something to help. .

The situation has since improved, with more reliable tests, faster turnaround times and established treatments that reduce the use of antibiotics in COVID-19 patients. In cases where empirical antibiotics are prescribed due to concerns about bacterial co-infections, they are quickly discontinued.

Antibiotic initiation has remained high, however, and there are concerns that overprescribing antibiotics in COVID-19 patients is one of the contributing factors to an increase in multidrug-resistant hospital-acquired infections.

But the statement is not so much a critique of antibiotic misuse during the pandemic as an acknowledgment of the challenges posed by COVID-19 and the difficulty of suppliers not using antibiotics in an environment of heightened disease and uncertainty. It is also an effort to establish evidence-based guidelines for how the health care system and antibiotic management programs (ASPs) should respond during the next public health emergency caused by viral respiratory disease, the lead author says.

“The point we were trying to make is that there are evidence-based principles you can follow…and we think these principles can be applied to the next respiratory viral epidemic,” Tamar Barlam, MD, director of Antimicrobial Stewardship at Boston Medical Center and chair of the SHEA Antimicrobial Stewardship Committee, CIDRAP told News.

‘Low threshold’ for antibiotic use

The high antibiotic use in the early months of the pandemic is certainly understandable, says Barlam. Hospitals were inundated with critically ill patients sick with a mysterious new respiratory disease, and little could be done for them. Doctors were very eager to do something for these patients, many of whom presented with bacterial pneumonia. There were also early media-driven reports that the antibiotic azithromycin could be effective.

All of these factors led to a “low threshold” for starting antibiotics, Barlam and her colleagues write.

“If we can remember there were no vaccines at the time, there were no treatments. It wasn’t clear if there was a role for some of the agents,” she said. “And in many ways, giving an antibiotic is just easier than really thinking about it.”

But even as testing became more reliable and patients came in with classic signs of COVID-19, prescribing antibiotics became an almost “knee jerk” response, with some patients receiving broad-spectrum drugs more suitable for hospital-related infections.

“It was not appropriate to treat someone who was essentially healthy until they got COVID as if they had hospital-associated pneumonia,” Barlam said. “But we saw it all the time.”

Another factor in the onset of the pandemic, and one that continues to drive antibiotic use in COVID-19 patients, is the concern about bacterial co-infections, especially in elderly patients with other morbidities. But Barlam and her colleagues note that studies have shown that only 3.1% to 5.5% of COVID-19 patients have bacterial co-infections.

To prevent this type of antibiotic use in future respiratory viral outbreaks, the SHEA statement first recommends that healthcare providers limit antibiotic initiation when there is a “high pre-test probability” of a viral infection, even in cases where accurate diagnosis is not possible. is possible. t available immediately.

“There is no evidence that routine antibiotics are needed for respiratory viral pandemics in patients who do not show obvious signs of bacterial co-infection,” the statement says.

The statement goes on to say that health care providers may perform inflammatory marker tests, such as C-reactive protein or procalcitonin tests, but those markers should not be used as a basis for starting antibiotics because they may not be indicative of a bacterial or fungal infection. infection.

Barlam and her colleagues recognize that it is important for health care providers to identify patients who may need antibiotics — such as those who have symptoms suggestive of bacterial pneumonia or other bacterial co-infection — and to conduct microbiological tests to detect the infection. and adjust antibiotic therapy accordingly. But they warn against overusing diagnostic tests if there are no signs of bacterial co-infection.

The role of stewardship

Finally, the SHEA statement highlights the important role ASPs can play in future outbreaks or pandemics, not just in terms of developing treatment guidelines and monitoring appropriate antibiotic use. ASPs can also provide clinicians with advice and support in the face of clinical uncertainty and, as they have done during the COVID-19 pandemic, help evaluate and implement other treatment regimens.

“Stewardship is actually part of an emergency response,” Barlam said.

Barlam knows that when a viral outbreak or pandemic occurs, the challenges seen during COVID are likely to resurface. But she hopes the statement clearly describes the evidence-based steps health care providers should take to minimize unnecessary antibiotic use in that case.

“I think we know that if there’s another major outbreak, we’re going to have to strengthen and re-educate and provide guidance,” she said. “But it’s always good to organize it so that you have a common lexicon from which to work.”

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