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 researchers documented community-onset bacterial coinfection in only 3.5%.

SOURCE: Vaughn VM, Gandhi T, Petty LA, et al. Empiric antibacterial therapy and community-onset bacterial coinfection 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, 56.6% were prescribed early empiric antibacterial therapy. Researchers identified confirmed community-onset bacterial infection in 3.5%. Across hospitals, the use of early empiric antibiotics varied from 27% to 84%. Patients more likely to receive early empiric antibiotic therapy included those who were older (adjusted rate ratio [ARR], 1.04 per 10 years of age), weighed less (ARR, 0.99 per kg/m2), sicker (ARR, 1.16), exhibited lobar infiltrate on imaging (ARR, 1.21), or admitted to a for-profit hospital (ARR, 1.30). Between March and April 2020, as COVID-19 test turnaround time improved, the use of early empiric antibiotic use declined (ARR, 0.71).

COMMENTARY

Despite the low prevalence of concomitant bacterial infection present at admission, many patients received early empiric antibacterial therapy. Shortening COVID-19 test turnaround time modestly reduced early empiric antibiotic use, 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 positive COVID-19 test results are available for the patient in the ED. It also is likely that since many COVID-19 patients meet criteria for “sepsis,” CMS SEP-1 bundles are triggered, and it often is easier to start antibiotics than to justify why antibiotics are not administered to patients with viral infection. This unfortunate aspect of mandatory SEP-1 bundles is one reason 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].