Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study

Abstract

Background Antibacterials may be initiated out of concern for bacterial co-infection in patients with COVID-19. We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial co-infections in hospitalized patients with COVID-19. Methods Randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020-6/18/2020. Data were collected on early (prescribed within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial co-infections (positive culture or diagnostic test within 3 days). Poisson generalized estimating equation models were used to assess predictors of empiric antibacterial use. Results Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27%-84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years), had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m 2), had more severe illness (e.g., severe sepsis, ARR: 1.16 [1.07-1.27]), had a lobar infiltrate (ARR: 1.21 [1.04-1.42]), or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs. in April [85.2%, 628/737], P<.001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs. March) decreased. Conclusion The prevalence of confirmed community-onset bacterial co-infections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.

Few bacterial co-infections but frequent empiric antibiotic use in the early phase of hospitalized patients with COVID-19: results from a multicentre retrospective cohort study in The Netherlands

“…Local guideline adherences for empiric antibiotic treatment was moderate and iv to oral switch was infrequently performed. The low incidence of bacterial co-infections is in line with three other studies [8][9][10]. S. aureus, S. pneumoniae and Gram-negative bacteria have been isolated most commonly [5,6,8,9].…”

“…Microbiological diagnostics performed also differed per hospital with, overall, blood cultures being performed most and sputum cultures least frequently, corresponding to a recent study [8]. The low frequency of sputum cultures can also be explained by the frequent presence of a non-productive cough, which is more frequent in COVID-19 than in community-acquired bacterial pneumonia [10]. Intriguingly, a PUAT was performed in the minority of patients, even if patients received (broad spectrum) empiric antibiotic treatment.…”

“…Few studies have described detailed data on the timing of co-infections. Early bacterial co-infections, predominantly originating from the respiratory tract, occurred in approximately 3% in three studies [8][9][10]. This proportion rose to 6% in one study when the entire hospital admission was included [8].…”

Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study

“…Nonrespiratory infections included BSI in 20 patients (2%), UTI in 30 patients (3%), and CDI in 2 patients (0.2%). The most common blood pathogens included Staphylococcus aureus [ 6 ], coagulase-negative Staphylococcus [ 5 ], and Escherichia coli [ 5 ], and the most common urinary pathogens were E. coli [ 10 ], Proteus spp. [ 5 ], and Klebsiella spp.…”

Accounting for variation in and overuse of antibiotics among humans

“…Early in the outbreak, when physicians were faced with severely ill patients with high fevers, even though they knew that the ultimate cause was a virus (SARS‐CoV‐2), they began empiric antibiotic treatment for suspected bacterial superinfection out of proportion to the real indications. [ 185 ] In the moment of crisis, antibiotic use for suspected bacterial infections was the default approach, regardless of indication. Physicians cared deeply for their critically ill patients, and with a dearth of evidence, responded with the now time‐honored approach, empiric antibiotics; whether these improved or worsened outcomes was not determined.…”