By Dean L. Winslow, MD, FACP, FIDSA, FPIDS

Professor of Medicine, Division of General Medical Disciplines, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine

Dr. Winslow reports no financial relationships relevant to this field of study.

SYNOPSIS: Fifty-seven percent of patients with COVID-19 infection treated at 38 hospitals in Michigan received early empiric antibiotics, although only 3.5% of patients had documented community-onset bacterial co-infection.

SOURCE: Vaughn VM, Gandhi T, Petty LA, et al. Empiric antibacterial therapy and community-onset bacterial co-infection in patients hospitalized with COVID-19: A multi-hospital cohort study. Clin Infect Dis 2020; Aug. 21. doi: 10.1093/cid/ciaa1239. [Online ahead of print].

Researchers studied 1,705 randomly selected patients hospitalized with COVID-19 at 38 Michigan hospitals. Of those patients, 56.6% were prescribed early empiric antibacterial therapy. A confirmed community-onset bacterial infection was identified in 3.5% of patients. Across hospitals, the use of early empiric antibiotics varied from 27% to 84%. Patients more likely to receive early empiric antibiotic therapy included patients who were older (adjusted rate ratio [ARR], 1.04 per 10 years of age), had lower body mass index (ARR, 0.99 per kg/m2), had more severe illness/sepsis (ARR, 1.16), had lobar infiltrate present on imaging (ARR, 1.21), or were admitted to a for-profit hospital (ARR, 1.30). Between March and April of this year, as COVID-19 test turnaround time improved, the use of early empiric antibiotic use declined (ARR, 0.71).

COMMENTARY

Despite the very low prevalence of concomitant bacterial infection present at the time of admission to the hospital, a very high percentage of patients received early empiric antibacterial therapy. Reducing COVID-19 test turnaround time modestly reduced the use of early empiric antibiotics, but use still was quite high. My sense from observing practice at my own hospital is that doctors often use antibiotics out of “fear of missing something” even when the patients have positive COVID-19 test results available in the emergency department. It also is likely that, since many COVID-19 patients meet criteria for “sepsis,” Centers for Medicare and Medicaid Services (CMS) SEP-1 bundles are triggered, and it often is easier to start antibiotics than to justify why antibiotics are not given to patients with viral infection. This unfortunate aspect of mandatory SEP-1 bundles is one of the reasons why the Infectious Diseases Society of America recently withdrew its endorsement of the Society of Critical Care Medicine’s “Surviving Sepsis Campaign Guidelines”1 and has endorsed modification of the CMS SEP-1 bundles.2 Inappropriate overuse of antibiotics in COVID-19 patients is an excellent target for hospital antimicrobial stewardship.

REFERENCES

  1. Kalil A, Gilbert D, Winslow DL, et al. Infectious Diseases Society of America (IDSA) Position Statement: Why IDSA did not endorse the Surviving Sepsis Campaign guidelines. Clin Infect Dis 2018;66:1631-1635.
  2. Rhee C, Chiotos K, Cosgrove SE, et al. Infectious Diseases Society of America Position Paper: Recommended revisions to the national SEP-1 sepsis quality measure. Clin Infect Dis 2020; ciaa059. [Online ahead of print].