Antibiotic Use and Bacterial Infection among Inpatients in the First Wave of COVID-19: a Retrospective Cohort Study of 64,691 Patients

Abstract

Background: Hospitalized patients with SARS-CoV-2 infection (COVID-19) often receive antibiotics for suspected bacterial co-infection. We estimated the incidence of bacterial co-infection and secondary infection in COVID-19 using clinical diagnoses to determine how frequently antibiotics are administered when bacterial infection is absent. Methods: We performed a retrospective cohort study of inpatients with COVID-19 present on admission to hospitals in the Premier Healthcare Database between April – June 2020. Bacterial infections were defined using ICD-10-CM diagnosis codes and associated “present on admission” coding. Co-infections were defined by bacterial infection present on admission, while secondary infections were defined by bacterial infection that developed after admission. Co-infection and secondary infection were not mutually exclusive. Results: 18.5% of 64,961 COVID-19 patients (n=12,040) presented with bacterial infection at admission, 3.8% (n=2,506) developed secondary infection after admission, and 0.9% (n=574) had both. 76.3% (n=49,551) received an antibiotic while hospitalized, including 71% of patients who had no diagnosis of bacterial infection. Secondary bacterial infection occurred in 5.7% patients receiving steroids in the first 2 days of hospitalization, 9.9% receiving tocilizumab in the first 2 days of hospitalization, and 10.3% patients receiving both. After adjusting for patient and hospital characteristics, bacterial co-infection (aRR 1.15; 95% CI, 1.11 – 1.20) and secondary infection (aRR 1.93; 95% CI, 1.82 – 2.04) were both independently associated with increased mortality. Conclusions: Though 1 in 5 inpatients with COVID-19 present with bacterial infection, secondary infections in the hospital are uncommon. Most inpatients with COVID-19 receive antibiotic therapy, including 71% of those not diagnosed with bacterial infection.

Comparing the Occurrence of Healthcare-Associated Infections in Patients with and without COVID-19 Hospitalized during the Pandemic: A 16-Month Retrospective Cohort Study in a Hospital Intensive Care Unit

“…The exception was mechanical ventilation, which seemed to be protective, probably because of the depletion of susceptible patients, a selection bias typical of survival analysis. Furthermore, in contrast to other reports [ 46 , 47 ], we found that antibiotic consumption had a negative impact on HAIs acquisition although heterogeneously between classes of antibiotics and across periods. Interestingly, we found glycopeptides and macrolides among the protective factors; these were mostly prescribed in COVID-19 patients because of their therapeutic effect against SARS-CoV-2 pneumonia [ 48 , 49 ].…”

Presumed Urinary Tract Infection in Patients Admitted with COVID-19: Are We Treating Too Much?

“…Moreover, the few studies that do report on UTIs are solely based on microbiological diagnostic criteria, neglecting the importance of clinical diagnostic criteria [ 18 ]. Appropriateness studies focusing on UTI diagnoses and treatment are scarce, especially in the COVID-19 setting [ 6 , 9 , 14 , 21 , 22 ]. Reyes et al came with a warning concerning probable overdiagnosis and overtreatment of asymptomatic bacteriuria in COVID-19 patients, as they cited the Infectious Disease Society of America (IDSA), which recommends ‘the assessment for other causes and watchful observation of older patients with functional and/or cognitive impairment with bacteriuria and without local genitourinary symptoms rather than immediate antimicrobial treatment’.…”

“…Since the start of the pandemic, different studies have highlighted disproportional antimicrobial use in COVID-19 patients despite low bacterial co- and superinfection rates. Reported rates vary from 4 to 19%, depending on the geographical setting of the study, the inclusion or exclusion of patients admitted to the intensive care unit and the used definitions of co-/superinfections [ 4 , 5 , 6 , 7 , 8 , 9 ]. Most investigators differentiate between bacterial respiratory co-/superinfection and nonrespiratory co-/superinfection.…”

“…Of those, genitourinary infections were the most frequent (8.5% of the total population). However, according to the authors, this was probably an overestimation, as diagnoses were documented using diagnostic codes extracted from a federal database, and patient medical file review was not performed to confirm bacterial infection based on clinical criteria [ 9 ]. Additionally, urinary tract infections and asymptomatic bacteriuria (ASB) are frequently overdiagnosed and thus overtreated.…”

Bacterial Coinfections in COVID-19 Patients without a Positive Microbiologic Result: a Word of Caution

“…Following the publication of the retrospective study by Baghdadi and colleagues about bacterial infections and antibiotic use among coronavirus disease 2019 (COVID-19) patients ( 1 ), we have some concerns that we would like to report.…”