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Granata G, Cicalini S. The Evolving Challenge of Appropriate Antibiotics Use in Hospitalized COVID-19 Patients: A Systematic Literature Review. Antibiotics (Basel) 2024; 13:545. [PMID: 38927211 PMCID: PMC11200443 DOI: 10.3390/antibiotics13060545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
The issue of bacterial infections in COVID-19 patients has received increasing attention. Scant data are available on the impact of bacterial superinfection and antibiotic administration on the outcome of hospitalized COVID-19 patients. We conducted a literature review from 1 January 2022 to 31 March 2024 to assess the current burden of bacterial infection and the evidence for antibiotic use in hospitalized COVID-19 patients. Published articles providing data on antibiotic use in COVID-19 patients were identified through computerized literature searches with the search terms [(antibiotic) AND (COVID-19)] or [(antibiotic treatment) AND (COVID-19)]. PubMed and SCOPUS databases were searched from 1 January 2022 to 31 March 2024. No attempt was made to obtain information about unpublished studies. English language restriction was applied. The quality of the included studies was evaluated by the tool recommended by the Joanna Briggs Institute. Both quantitative and qualitative information were summarized by means of textual descriptions. Five hundred fifty-one studies were identified, and twenty-nine studies were included in this systematic review. Of the 29 included studies, 18 studies were on the prevalence of bacterial infection and antibiotic use in hospitalized COVID-19 patients; 4 studies reported on the efficacy of early antibiotic use in COVID-19; 4 studies were on the use of sepsis biomarkers to improve antibiotic use; 3 studies were on the efficacy of antimicrobial stewardship programs and predictive models among COVID-19-hospitalized patients. The quality of included studies was high in 35% and medium in 62%. High rates of hospital-acquired infections were reported among COVID-19 patients, ranging between 7.5 and 37.7%. A high antibiotic resistance rate was reported among COVID-19 patients developing hospital-acquired infections, with a high in-hospital mortality rate. The studies evaluating multi-faceted antimicrobial stewardship interventions reported efficacy in decreasing antibiotic consumption and lower in-hospital mortality.
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Affiliation(s)
- Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, 00149 Rome, Italy
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Hammarskjöld F, Berg S, Bavelaar H, Henningson AJ, Taxbro K. Pulmonary superinfection diagnosed with bronchoalveolar lavage at intubation in COVID patients: A Swedish single-centre study. Acta Anaesthesiol Scand 2024; 68:512-519. [PMID: 38282310 DOI: 10.1111/aas.14378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patients with severe coronavirus disease 2019 (COVID) pneumonia and acute respiratory distress syndrome (C-ARDS) on invasive mechanical ventilation (IMV) have been found to be prone to having other microbial findings than severe acute respiratory syndrome coronavirus 2 (SARS-2)-CoV-19 in the bronchoalveolar lavage (BAL) fluid at intubation causing a superinfection. These BAL results could guide empirical antibiotic treatment in complex clinical situations. However, there are limited data on the relationship between microbial findings in the initial BAL at intubation and later ventilator-associated pneumonia (VAP) diagnoses. OBJECTIVE To analyse the incidence of, and microorganisms responsible for, superinfections in C-ARDS patients at the time of first intubation through microbial findings in BAL fluid. To correlate these findings to markers of inflammation in plasma and later VAP development. DESIGN Retrospective single-centre study. SETTING One COVID-19 intensive care unit (ICU) at a County Hospital in Sweden during the first year of the pandemic. PATIENTS All patients with C-ARDS who were intubated in the ICU. RESULTS We analysed BAL fluid specimens from 112 patients at intubation, of whom 31 (28%) had superinfections. Blood levels of the C-reactive protein, procalcitonin, neutrophil granulocytes, and lymphocytes were indistinguishable between patients with and without a pulmonary superinfection. Ninety-eight (88%) of the patients were treated with IMV for more than 48 h and of these patients, 37% were diagnosed with VAP. The microorganisms identified in BAL at the time of intubation are normally found at the oral, pharyngeal, and airway sites. Only one patient had an indistinguishable bacterial strain responsible for both superinfection at intubation and in VAP. CONCLUSIONS One fourth of the patients with C-ARDS had a pulmonary superinfection in the lungs that was caused by another microorganism identified at intubation. Routine serum inflammatory markers could not be used to identify this complication. Microorganisms located in BAL at intubation were rarely associated with later VAP development.
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Affiliation(s)
- Fredrik Hammarskjöld
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Herjan Bavelaar
- Division of clinical Microbiology, Department of Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
| | - Anna J Henningson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Division of clinical Microbiology, Department of Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
| | - Knut Taxbro
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Sili U, Tekin A, Bilgin H, Khan SA, Domecq JP, Vadgaonkar G, Segu SS, Rijhwani P, Raju U, Surapaneni KM, Zabolotskikh I, Gomaa D, Goodspeed VM, Ay P. Early empiric antibiotic use in COVID-19 patients: results from the international VIRUS registry. Int J Infect Dis 2024; 140:39-48. [PMID: 38128643 PMCID: PMC10939992 DOI: 10.1016/j.ijid.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVES COVID-19 escalated inappropriate antibiotic use. We determined the distribution of pathogens causing community-acquired co-infections, the rate, and factors associated with early empiric antibiotic (EEAB) treatment among hospitalized COVID-19 patients. METHODS The Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry including 68,428 patients from 28 countries enrolled between January 2020 and October 2021 were screened. After exclusions, 7830 patients were included in the analysis. Azithromycin and/or other antibiotic treatment given within the first 3 days of hospitalization was investigated. Univariate and multivariate analyses were performed to determine factors associated with EEAB use. RESULTS The majority (6214, 79.4%) of patients received EEAB, with azithromycin combination being the most frequent (3146, 40.2%). As the pandemic advanced, the proportion of patients receiving EEAB regressed from 84.4% (786/931) in January-March 2020 to 65.2% (30/46) in April-June 2021 (P < 0.001). Beta-lactams, especially ceftriaxone was the most commonly used antibiotic. Staphylococcus aureus was the most commonly isolated pathogen. Multivariate analysis showed geographical location and pandemic timeline as the strongest independent predictors of EEAB use. CONCLUSIONS EEAB administration decreased as pandemic advanced, which may be the result of intensified antimicrobial stewardship efforts. Our study provides worldwide goals for antimicrobial stewardship programs in the post-COVID-19 era.
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Affiliation(s)
- Uluhan Sili
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Marmara University, Istanbul, Türkiye.
| | - Aysun Tekin
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Huseyin Bilgin
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Marmara University, Istanbul, Türkiye
| | - Syed Anjum Khan
- Division of Critical Care Medicine, Mayo Clinic Health System, Mankato, Minnesota, United States
| | - Juan Pablo Domecq
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Smitha S Segu
- Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Puneet Rijhwani
- Department of Medicine, Mahatma Gandhi University of Medical Sciences & Technology, Jaipur, Rajasthan, India
| | | | - Krishna Mohan Surapaneni
- Departments of Biochemistry, Molecular Virology, Research and Clinical Skills & Simulation, Panimalar Medical College Hospital & Research Institute, Varadharajapuram, Poonamallee, Chennai, Tamil Nadu, India
| | - Igor Zabolotskikh
- Department of Anesthesiology, Intensive Care Medicine and Transfusiology, Kuban State Medical University with affiliation Territorial Hospital #2, Krasnodar, Russia
| | - Dina Gomaa
- Department of Surgery Division of Trauma and Critical Care- Trauma Research University of Cincinnati, Cincinnati, Ohio, United States
| | - Valerie M Goodspeed
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Pinar Ay
- Department of Public Health, School of Medicine, Marmara University, Istanbul, Türkiye
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