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New research stresses the importance of antimicrobial stewardship when treating COVID-19. Westend61/Getty Images
  • Bacterial coinfections were rare among COVID-19 patients hospitalized during the first wave of the pandemic.
  • Despite little evidence of bacterial infections, a high proportion of patients received antimicrobials.
  • Researchers stress the importance of antimicrobial stewardship to prevent the rise of drug-resistant infections.

All data and statistics are based on publicly available data at the time of publication. Some information may be out of date.

Antimicrobial resistance is a major public health concern that threatens the ability to deal with common infections. Optimizing the use of antimicrobial, or antibiotic, medicines plays a critical role in effectively treating infections and limiting antibiotic resistance. This optimization is known as antimicrobial stewardship.

One aspect involves restricting the prescription of antimicrobial medicines before tests confirm that there is a bacterial infection, especially during hospital admission. A recent study published in The Lancet Microbe investigated the use of antimicrobials among COVID-19 patients hospitalized in the United Kingdom.

Bacterial coinfections are common in people with severe viral respiratory infections, such as influenza, and are often associated with increased rates of morbidity and mortality. As a result, doctors frequently prescribe antimicrobial therapy in these instances of coinfection.

Current U.K. guidelines caution against using antimicrobial therapy without specific evidence of a bacterial infection. However, numerous ongoing studies have reported a low prevalence of confirmed bacterial coinfection and a high proportion of COVID-19 patients receiving antimicrobials.

As part of an ongoing study involving the International Severe Acute Respiratory and Emerging Infections Consortium, researchers have analyzed inpatient data from 260 hospitals in England, Scotland, and Wales. Nearly 50,000 patients diagnosed with COVID-19 were admitted to these hospitals during the first wave of the pandemic, between February 6 and June 8, 2020.

Around 18%, or 8,649, of these patients were evaluated for microbiological infections upon admission. The microbiological tests included blood tests and analyses of sputum and deep lung samples.

Approximately 13%, or 1,107, of those tested showed COVID-19-related respiratory or bloodstream bacterial infections. By contrast, bacterial coinfections are much more common among people with severe influenza, occurring in 23% of patients in a 2013 meta-analysis.

Among the COVID-19 patients with available data, around 37% had received antimicrobials for this before they were admitted to the hospital. The researchers noted that despite the lack of evidence of bacterial infections, 85% of patients received antimicrobials during their hospital stay.

Broad-spectrum agents such as carbapenems, a class of antimicrobials reserved for the treatment of severe or high-risk bacterial infections, were used frequently and accounted for 3.8% of all prescriptions. Carbapenem-sparing, gram-negative active alternatives were less frequently prescribed, accounting for 0.2 to 1.5% of all prescriptions.

Co-author Dr. Antonia Ho says, “In making any assessment of the use of antimicrobials in the treatment of COVID-19 patients, it is essential to acknowledge that clinicians in the U.K., and worldwide, have been battling a global medical emergency.”

“Given the unprecedented challenges posed by the pandemic, particularly during its early stages, when admitted patients were very sick, effective treatments were limited, and the role of possible coinfections [was] unknown, it is unsurprising that doctors would prescribe antimicrobials.”

“However, we now know that bacterial coinfection is uncommon in patients with community-acquired COVID-19.”

The researchers acknowledge several limitations of their study. One challenge is dealing with the retrospective aspect, especially when attempting to distinguish between a true infection and other plausible explanations. It was often impossible to differentiate new infections in people with chronic lung disease since previous microbiology results were not available.

In addition, receiving antimicrobial medicines before sampling could have led to an inaccurate count of true bacterial infections.

The findings suggest that adopting antimicrobial stewardship for COVID-19 patients will help slow the antimicrobial resistance crisis.

“Since antimicrobial resistance remains one of the biggest public health challenges of our time, measures to combat it are essential to help ensure that these lifesaving medicines remain an effective treatment for infection in years to come.”

– Dr. Antonia Ho

The study’s authors recommend that several stewardship actions be prioritized for incorporation into COVID-19 patient care.

These actions include restricting antimicrobial prescriptions without a confirmed diagnosis, especially at hospital admission, tailoring the choice of antimicrobial to likely pathogens and local resistance patterns, and encouraging clinicians to discontinue antimicrobials if coinfection is deemed unlikely and tests confirm that there is no bacterial infection.

Co-author Dr. Clark Russell notes: “Our findings add much-needed depth to our understanding of how antimicrobials have been used in the treatment of patients with COVID-19 and how antimicrobial usage could be optimized. Prioritizing and incorporating existing antimicrobial stewardship principles into care plans could help to prevent a rise of drug-resistant infections [from] becoming a longer-term sequel of the pandemic.”

“Our study looked at only the first pandemic wave in the U.K., so it is important that future studies assess antimicrobial usage later in the pandemic, both in the U.K. and other parts of the world.”

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