The interface between COVID-19 and bacterial healthcare-associated infections

Abstract

Background A wide range of bacterial infections occur in COVID-19 patients, particularly, in those with severe coronaviral disease. Some of these are community acquired co-infections. Objective To review recent data which indicate the occurrence of hospital-onset bacterial infections, including with antibiotic-resistant isolates, in COVID-19 patients. Sources Using PubMed, the literature was searched using terms including: “COVID-19”; “SARS-CoV-2”; “bacterial infection”; “healthcare-associated infection”; “antibiotic resistance”; “antimicrobial resistance”; “multi-drug resistance”; “ Streptococcus ”; “ Staphylococcus ”; “ Pseudomonas ”; “ Escherichia ”; “ Klebsiella ”; “ Enterococcus ”; “ Acinetobacter ”; “ Haemophilus ”; “MRSA”; “VRE”; “ESBL”; “NDM-CRE”; “CR-Ab”; “VRSA”; “MDR”. Content There is a growing number of reports of bacterial infections acquired by patients with severe COVID-19 after hospital admission. Antibiotic-resistant pathogens found to cause healthcare-associated infections (HAIs) in COVID-19 patients include Methicillin-Resistant Staphylococcus aureus (MRSA), New Delhi Metallo-β-lactamase-producing Carbapenem-Resistant Enterobacterales (NDM-CRE), Carbapenem-Resistant Acinetobacter baumannii (CR-Ab), Extended-Spectrum β-Lactamase (ESBL) Klebsiella pneumoniae , and Vancomycin-Resistant Enterococci (VRE). COVID-19 has impacted bacterial HAIs in a number of ways with an increase in the incidence of NDM-CRE and CR-Ab reported at some hospital sites compared to before the pandemic. Recommended guidelines for antimicrobial stewardship in COVID-19 patient treatment are discussed regarding minimisation of empiric broad-spectrum antibiotic use. Other studies have reported a decrease in MRSA and VRE cases that has been attributed to enhanced infection prevention and control (IPC) practices introduced to minimise intra-hospital spread of COVID-19. Implications Poorer outcomes have been observed in hospitalised COVID-19 patients with an antibiotic-resistant infection. While heightened IPC measures have been accompanied by a reduction in some HAIs at specific sites, in other situations, COVID-19 has been associated with an increase in bacterial HAI incidence. Further research is needed to define the cost-benefit relationship of maintaining COVID-19-related IPC protocols beyond the pandemic to reduce the burden of HAIs. In addition, the longer-term impact of high usage of certain broad-spectrum antibiotics during the COVID-19 pandemic requires evaluation.

COVID-19: Impact on prescribing and antimicrobial resistance

“…The impact of changing antimicrobial prescribing on antimicrobial resistance has been highlighted by several authors [7,[20][21][22][23]. The evidence so far has been clearest in the hospital setting where the relevant increase in prescribing of antimicrobials with wide-spectrum, the higher selection density, the difficulty to continue the adherence to epidemiological barrier measures and the discontinuation of antimicrobial stewardship programs may have been the cause of the increase of antimicrobial resistance.…”

“…There is a growing number of reports of superinfection caused by ESKAPE pathogens, especially carbapenemase-producing Enterobacterales , in patients with severe COVID-19 during hospitalization [ 7 ]. The local ecology, represented by the pool of resistance genes and circulating high-risk clones (HiRCs) plays an important role in the epidemiology of MDR bacteria in the hospital setting during the COVID-19 pandemic.…”

“…These pathogens have been associated mainly with hospital and ventilator-acquired pneumonia, particularly in the ICU cohorts. Among the gram-positive bacteria, coagulase-negative staphylococci as well as Enterococcus faecalis and Enterococcus faecium, following by S. aureus are the most common and mainly caused of BSIs [5][6][7].…”

High Rates of Bacterial Pulmonary Co-Infections and Superinfections Identified by Multiplex PCR among Critically Ill COVID-19 Patients

“…Superinfection may be becoming more of an issue now because of increased length of ICU stay secondary to improved overall COVID-19 survival rates, the now universal use of corticosteroid therapy and increased use of other immunomodulatory drugs such as tocilizumab and baricitinib, and improved reports from focused studies conducted to assess COVID-19-related infectious complications. Outbreaks of multidrug resistant bacteria are also commonly reported, including a variety of organisms such as carbapenem resistant Acinetobacter baumannii, carbapenem resistant Enterobacterales, multidrug resistant Pseudomonas aeruginosa, methicillin resistant Staphylococcus aureus (MRSA), Candida auris and others [2,[16][17][18]. Since most COVID-19 patients in the ICUs are treated empirically with antimicrobials [4,19], antibiotic stewardship programs along with enhanced infection control protocols are essential in controlling the emergence of these dreaded infections.…”

Cotton Fabrics Decorated with Antimicrobial Ag-Coated TiO2 Nanoparticles Are Unable to Fully and Rapidly Eradicate SARS-CoV-2

“…Moreover, it is crucial to avoid bacterial coinfection of COVID-19 patients that can enhance their risk of death and the emergence of new antibiotic-resistant bacteria associated with treatments with high content of antibiotics. 5 , 6 …”