Inadequate use of antibiotics in the covid-19 era: effectiveness of antibiotic therapy

The Impact of Early Antibiotic Use on Clinical Outcomes of Patients Hospitalized with COVID-19: A Propensity Score-Matched Analysis

Purpose

Early empiric antibiotics were prescribed to numerous patients during the Coronavirus disease 2019 (COVID-19) pandemic. However, the potential impact of empiric antibiotic therapy on the clinical outcomes of patients hospitalized with COVID-19 is yet unknown.

Methods

In this retrospective cohort study, early antibiotics use cohort was defined as control group, which was compared with no antibiotic use and delayed antibiotic use cohorts for all-cause mortality during hospitalization. The 1:2 propensity score matched patient populations were further developed to adjust confounding factors. Survival curves were compared between different cohorts using a Log rank test to assess the early antibiotic effectiveness.

Results

We included a total of 1472 COVID-19 hospitalized patients, of whom 87.4% (1287 patients) received early antibiotic prescriptions. In propensity-score-matched datasets, our analysis comprised 139 patients with non-antibiotic use (with 278 matched controls) and 27 patients with deferred-antibiotic use (with 54 matched controls). Patients with older ages, multiple comorbidities, severe and critical COVID-19 subtypes, higher serum infection indicators, and inflammatory indicators at admission were more likely to receive early antibiotic prescriptions. After adjusting confounding factors likely to influence the prognosis, there is no significant difference in all-cause mortality (HR=1.000(0.246-4.060), p = 1.000) and ICU admission (HR=0.436(0.093-2.04), p = 0.293), need for mechanical ventilation (HR=0.723(0.296-1.763), p = 0.476) and tracheal intubation (HR=1.338(0.221-8.103), p = 0.751) were observed between early antibiotics use cohort and non-antibiotic use cohort.

Conclusion

Early antibiotics were frequently prescribed to patients in more severe disease condition at admission. However, early antibiotic treatment failed to demonstrate better clinical outcomes in hospitalized patients with COVID-19 in the propensity-score-matched cohorts.

Impact of antibiotic therapy in patients with respiratory viral infections: a retrospective cohort study

OBJECTIVES

The impact of antibiotics in patients with positive polymerase chain reaction (PCR) for respiratory viruses without evidence of a respiratory bacterial co-infection is largely unknown. The aim of this study was to assess the association of antibiotics on 30-day mortality and length of hospital stay in patients with an acute respiratory infection and PCR documented presence of respiratory viruses.

METHODS

We conducted a retrospective cohort study of adult patients admitted to hospital between 2012 and 2021 with positive PCR for influenza virus (H3N2, H1N1, influenza B), respiratory syncytial virus, human metapneumovirus or severe acute respiratory syndrome coronavirus 2. We used logistic regression, the Kaplan-Meier estimator and Poisson's regression to assess the impact of antibiotic therapy on outcomes.

RESULTS

Among 3979 patients, 67.7% received antibiotics. In adjusted analyses, antibiotics initiated in the emergency department (adjusted OR 1.23, 95% CI 0.77-1.96) and days of antibiotic therapy (adjusted OR per day of therapy 0.98, 95% CI 0.95-1.00) had no significant impact on mortality, whereas antibiotics initiated later during admission (adjusted OR 2.25, 95% CI 1.26-4.02) was associated with increased mortality. Patients prescribed antibiotics had longer duration of hospital admission.

CONCLUSIONS

We observed no protective association between in-hospital antibiotic therapy and outcomes, suggesting overuse of antibiotics in respiratory infections with proven respiratory viruses. A restrictive antibiotic strategy may be warranted.

Is there a correlation between antibiotic use and the severity or post-infection conditions of COVID-19 and other viral infections?

Antibiotics are one of the most frequently prescribed medications in modern medicine; besides treating bacterial infections, they may often be utilized for prophylactic purposes, including during select viral infections. It has been shown that 74.9% of COVID-19 patients received antibiotics as a part of their treatment regimen during the pandemic. However, studies suggest that the actual incidence of bacterial coinfection was relatively uncommon with a mere 3.5% of overall cases reported. A recent study revealed that antibiotic administration would not improve disease progression or shorten the length of hospitalization in COVID-19 patients; additionally, some antibiotics, such as linezolid, promote the production of free radicals that might be responsible for exacerbated clinical symptoms during and post-infection. Notably, antibiotic use disturbs the normal gut microbiome, and this interference impedes antiviral immune response enhancing severity and susceptibility to a list of viral infections. Thus, resultant augmented severity of these infections may be a consequence of higher susceptibility to respiratory viral co-infection.

Antimicrobial Therapy as a Risk Factor of Multidrug-Resistant Acinetobacter Infection in COVID-19 Patients Admitted to the Intensive Care Unit

Background

Multidrug-resistant Acinetobacter (MDR-Ab) is one of the most important pathogens causing superinfections in COVID-19 patients hospitalised in the intensive care unit (ICU). The occurrence of MDR-Ab superinfection significantly impairs the prognosis of patients in the ICU. Overuse of antibiotics in COVID-19 patients might contribute to the risk of developing MDR-Ab infection.

Objective

The objective was to assess the role of prior antibiotic exposure as an independent predictor of MDR-Ab infection in COVID-19 patients admitted to the ICU.

Methods

We conducted a retrospective cohort study in 90 patients admitted to the ICU of the Department of Infectology and Geographical Medicine, University Hospital in Bratislava, for respiratory failure due to COVID-19 between 1 September 2021 and 31 January 2022 (delta variant predominance). Patients underwent regular microbial screening. Superinfection was defined as infection occurring ≥48 h after admission. We assessed the role of prior antibiotic exposure and other factors as independent predictors of MDR-Ab isolation.

Results

Fifty-eight male and 32 female patients were included in the analysis. Multidrug-resistant bacteria were cultured in 43 patients (47.8%), and MDR-Ab was isolated in 37 patients. Thirty-three (36.7%) patients had superinfection caused by MDR-Ab. Fifty-four (60%) patients were exposed to antibiotics prior to MDR-Ab isolation; of those, 35 (64.8%) patients received ceftriaxone. Prior exposure to ceftriaxone (odds ratio (OR) 4.1; 95% confidence interval (CI) 1.4-11.9; P < 0.05), tocilizumab therapy (OR 4.7; 95% CI 1.3-15.0; P < 0.05), and ICU length of stay exceeding 11 days (OR 3.7; 95% CI 1.3-10.3; P < 0.05) were independent predictors of MDR-Ab infection.

Conclusions

Prior exposure to ceftriaxone increases the risk of MDR-Ab infection in COVID-19 patients admitted to the ICU. Our findings suggest that antibiotic use in COVID-19 patients admitted to the ICU should be restricted to patients with documented bacterial superinfection.

Prediction of tsunami of resistance to some antibiotics is not far-fetched which used during COVID-19 pandemic

One of the most tragic events in recent history was the COVID-19 outbreak, which has caused thousands of deaths. A variety of drugs were prescribed to improve the condition of patients, including antiparasitic, antiviral, antibiotics, and anti-inflammatory medicines. It must be understood, however, that COVID-19 is like a tip of an iceberg on the ocean, and the consequences of overuse of antibiotics are like the body of a mountain under water whose greatness has not yet been determined for humanity, and additional study is needed to understand them. History of the war between microbes and antimicrobial agents has shown that microbes are intelligent organisms that win over antimicrobial agents over time through many acquired or inherent mechanisms. The key terms containing "COVID-19," "Severe acute respiratory syndrome coronavirus-2," "SARS-CoV2," "Antibiotic Resistance," "Coronavirus," "Pandemic," "Antibiotics," and "Antimicrobial Resistance" were used for searching in PubMed, Scopus, and Google Scholar databases. The COVID-19 pandemic has resulted in an increased prescription of antibiotics. Infections caused by secondary or co-bacterial infections or beneficial bacteria in the body can be increased as a result of this amount of antibiotic prescription and exposure to antibiotics. Antibiotic resistance will likely pose a major problem in the future, especially for last resort antibiotics. In order to address the antibiotic resistance crisis, it is imperative that researchers, farmers, veterinarians, physicians, public and policymakers, pharmacists, other health and environmental professionals, and others collaborate during and beyond this pandemic.

The Dark Side of Nosocomial Infections in Critically Ill COVID-19 Patients

Coronavirus disease 2019 (COVID-19) is a potentially serious acute respiratory infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Since the World Health Organization (WHO) declared COVID-19 a global pandemic, the virus has spread to more than 200 countries with more than 500 million cases and more than 6 million deaths reported globally. It has long been known that viral respiratory tract infections predispose patients to bacterial infections and that these co-infections often have an unfavourable clinical outcome. Moreover, nosocomial infections, also known as healthcare-associated infections (HAIs), are those infections that are absent at the time of admission and acquired after hospitalization. However, the impact of coinfections or secondary infections on the progression of COVID-19 disease and its lethal outcome is still debated. The aim of this review was to assess the literature on the incidence of bacterial co-infections and superinfections in patients with COVID-19. The review also highlights the importance of the rational use of antibiotics in patients with COVID-19 and the need to implement antimicrobial stewardship principles to prevent the transmission of drug-resistant organisms in healthcare settings. Finally, alternative antimicrobial agents to counter the emergence of multidrug-resistant bacteria causing healthcare-associated infections in COVID-19 patients will also be discussed.

What’s old is new again: Insights into diabetic foot microbiome

Diabetes is a chronic disease that is considered one of the most stubborn global health problems that continues to defy the efforts of scientists and physicians. The prevalence of diabetes in the global population continues to grow to alarming levels year after year, causing an increase in the incidence of diabetes complications and health care costs all over the world. One major complication of diabetes is the high susceptibility to infections especially in the lower limbs due to the immunocompromised state of diabetic patients, which is considered a definitive factor in all cases. Diabetic foot infections continue to be one of the most common infections in diabetic patients that are associated with a high risk of serious complications such as bone infection, limb amputations, and life-threatening systemic infections. In this review, we discussed the circumstances associated with the high risk of infection in diabetic patients as well as some of the most commonly isolated pathogens from diabetic foot infections and the related virulence behavior. In addition, we shed light on the different treatment strategies that aim at eradicating the infection.

Pharmacist-driven antimicrobial stewardship interventions in patients with COVID-19: a scoping review

BACKGROUND

Coronavirus Disease 2019 (COVID-19) is a highly infectious disease that can be treated with antivirals in addition to other antimicrobials in cases of secondary or concomitant infections. This creates potential for antimicrobials misuse, which increases antimicrobial resistance (AMR). Pharmacists are known to undertake prominent roles in combatting AMR.

AIM

The aim of this review was to characterize pharmacist-driven interventions that have been performed in patients with COVID-19 globally and describe their impact on antimicrobial use.

METHOD

We followed the Joanna Briggs Institutes manual framework for scoping reviews in our study. Studies that reported antimicrobial stewardship (AMS) interventions performed by pharmacists in COVID-19 patients were included. Articles that did not report outcomes or did not mention pharmacists in the intervention were excluded. Restrictions included English-only articles from inception date until June 2022. Articles were searched from four databases.

RESULTS

Eleven publications were included in the review. The most common AMS intervention was pharmacist-driven interventions reported in 63.2% of all studies, followed by guideline development and application (26.3%), and medication supply coordination (10.5%), respectively. The outcomes of the interventions were difficult to compare but showed a reduction in antimicrobial use and prevention of adverse drug reactions with a relatively high acceptance rate from physicians.

CONCLUSION

Pharmacists played an important role in performing AMS-related interventions in COVID-19 patients and helped in the fight against the worsening of AMR during the pandemic. The impact of pharmacist-driven AMS interventions in patients with COVID-19 seemed to be positive and improved outcomes related to antimicrobial use.

Can photocatalysis help in the fight against COVID-19 pandemic?

Mould fungi are serious threats to humans and animals (allergen) and might be the main cause of COVID-19-associated pulmonary aspergillosis. The common methods of disinfection are not highly effective against fungi due to the high resistance of fungal spores. Recently, photocatalysis has attracted significant attention towards antimicrobial action. Outstanding properties of titania photocatalysts have already been used in many areas, e.g., for building materials, air conditioner filters, and air purifiers. Here, the efficiency of photocatalytic methods to remove fungi and bacteria (risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 co-infection) is presented. Based on the relevant literature and own experience, there is no doubt that photocatalysis might help in the fight against microorganisms, and thus prevent the severity of COVID-19 pandemic.

Biopsychosocial analysis of antibiotic use for the prevention or management of COVID-19 infections: A scoping review

BACKGROUND

The novelty and complexity of the COVID-19 pandemic has resulted in various coping mechanisms adopted by individuals as a means of averting the perceived fatalities of the pandemic. The use of antibiotics in the management of COVID-19 is clinically recommended under specific conditions. However, there are increasing trends of non-adherence to the recommended criteria resulting in the unwarranted use of antibiotics as an adaptative approach to the ongoing pandemic.

OBJECTIVE

The objective was to identify and classify factors associated with the unwarranted use of antibiotics in the management of COVID-19 from published literature and the perspectives of key stakeholders along a Biopsychosocial model.

METHODS

Literature was searched in the following databases: PubMed/MEDLINE, Scopus, Embase and Google Scholar for studies published between 31st December 2019 and 31st January 2022. The Arskey and O'Malley framework modified by Levac in the six-stage methodological process was adopted for this review and included: a) identification of research questions, b) identification of relevant research articles, c) selection of studies, d) data charting and synthesis, e) summary, discussion and analysis, and f) stakeholder consultations.

RESULTS

Out of 10,252 records identified from all sources, 12 studies were selected for inclusion in this scoping review. The selected articles reflected both antibiotic use and COVID-19 whilst capturing the biological (medical) and psychosocial perspectives. Most of the studies reported the overuse or abuse of Azithromycin especially in hospital settings. Common themes across the review and stakeholder consultations included fear, anxiety, media influences and deficits in public knowledge.

CONCLUSION

The findings of the study highlight the complexity of antibiotic control especially in the context of a pandemic. The identified determinants of antibiotic use provide the necessary framework to simulate health emergencies and be better positioned in the future through the development of targeted and comprehensive policies on antibiotic stewardship.

Artificial Intelligence: A Next-Level Approach in Confronting the COVID-19 Pandemic

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which caused coronavirus diseases (COVID-19) in late 2019 in China created a devastating economical loss and loss of human lives. To date, 11 variants have been identified with minimum to maximum severity of infection and surges in cases. Bacterial co-infection/secondary infection is identified during viral respiratory infection, which is a vital reason for morbidity and mortality. The occurrence of secondary infections is an additional burden to the healthcare system; therefore, the quick diagnosis of both COVID-19 and secondary infections will reduce work pressure on healthcare workers. Therefore, well-established support from Artificial Intelligence (AI) could reduce the stress in healthcare and even help in creating novel products to defend against the coronavirus. AI is one of the rapidly growing fields with numerous applications for the healthcare sector. The present review aims to access the recent literature on the role of AI and how its subfamily machine learning (ML) and deep learning (DL) are used to curb the pandemic's effects. We discuss the role of AI in COVID-19 infections, the detection of secondary infections, technology-assisted protection from COVID-19, global laws and regulations on AI, and the impact of the pandemic on public life.

A multicentre study reveals dysbiosis in the microbial co-infection and antimicrobial resistance gene profile in the nasopharynx of COVID-19 patients

The impact of SARS-CoV-2 infection on the nasopharyngeal microbiome has not been well characterised. We sequenced genetic material extracted from nasopharyngeal swabs of SARS-CoV-2-positive individuals who were asymptomatic (n = 14), had mild (n = 64) or severe symptoms (n = 11), as well as from SARS-CoV-2-negative individuals who had never-been infected (n = 5) or had recovered from infection (n = 7). Using robust filters, we identified 1345 taxa with approximately 0.1% or greater read abundance. Overall, the severe cohort microbiome was least diverse. Bacterial pathogens were found in all cohorts, but fungal species identifications were rare. Few taxa were common between cohorts suggesting a limited human nasopharynx core microbiome. Genes encoding resistance mechanisms to 10 antimicrobial classes (> 25% sequence coverages, 315 genes, 63 non-redundant) were identified, with β-lactam resistance genes near ubiquitous. Patients infected with SARS-CoV-2 (asymptomatic and mild) had a greater incidence of antibiotic resistance genes and a greater microbial burden than the SARS-CoV-2-negative individuals. This should be considered when deciding how to treat COVID-19 related bacterial infections.

A multicenter evaluation of antibacterial use in hospitalized patients through the SARS-Cov-2 pandemic waves

BACKGROUND

Excessive use of antibiotics has been reported during the SARS-CoV-2 pandemic. We evaluated trends in antibiotic use and culture positive Gram-negative (GN)/Gram-positive (GP) pathogens in US hospitalized patients before and during the SARS-CoV-2 pandemic.

METHODS

This multicenter, retrospective study included patients from 271 US facilities with > 1-day inpatient admission with discharge or death between July 1, 2019, and October 30, 2021, in the BD Insights Research Database. We evaluated microbiological testing data, antibacterial use, defined as antibacterial use ≥ 24 h in admitted patients, and duration of antibacterial therapy.

RESULTS

Of 5,518,744 patients included in the analysis, 3,729,295 (67.6%) patients were hospitalized during the pandemic with 2,087,774 (56.0%) tested for SARS-CoV-2 and 189,115 (9.1%) testing positive for SARS-CoV-2. During the pre-pandemic period, 36.2% were prescribed antibacterial therapy and 9.3% tested positive for select GN/GP pathogens. During the SARS-CoV-2 pandemic, antibacterial therapy (57.8%) and positive GN/GP culture (11.9%) were highest in SARS-CoV-2-positive patients followed by SARS-CoV-2-negative patients (antibacterial therapy, 40.1%; GN/GP, pathogens 11.0%), and SARS-CoV-2 not tested (antibacterial therapy 30.4%; GN/GP pathogens 7.2%). Multivariate results showed significant decreases in antibacterial therapy and positive GN/GP cultures for both SARS-CoV-2-positive and negative patients during the pandemic, but no significant overall changes from the pre-pandemic period to the pandemic period.

CONCLUSIONS

There was a decline in both antibacterial use and positive GN/GP pathogens in patients testing positive for SARS-CoV-2. However, overall antibiotic use was similar prior to and during the pandemic. These data may inform future efforts to optimize antimicrobial stewardship and prescribing.

Use of Systemic Antibiotics in Patients with COVID-19 in Colombia: A Cross-Sectional Study

Antibiotics are frequently prescribed to patients with COVID-19. The aim was to determine the pattern of use of systemic antibiotics in a group of patients diagnosed with COVID-19 in Colombia between 2020-2022. This was a descriptive cross-sectional study designed to identify antibiotics prescription patterns for patients diagnosed with COVID-19 treated in eight clinics in Colombia. The AWaRe tool of the World Health Organization (WHO) was used to classify the antibiotics. A total of 10,916 patients were included. The median age was 57 years, and 56.4% were male. A total of 57.5% received antibiotics, especially ampicillin/sulbactam (58.8%) and clarithromycin (47.9%). Most of the antibiotics were classified as Watch (65.1%), followed by Access (32.6%) and Reserve (2.4%). Men (OR: 1.29; 95%CI: 1.17-1.43), older adults (OR: 1.67; 95%CI: 1.48-1.88), patients with dyspnea (OR: 1.26; 95%CI: 1.13-1.41), rheumatoid arthritis (OR: 1.94; 95%CI: 1.17-3.20), and high blood pressure at admission (OR: 1.45; 95%CI: 1.29-1.63), patients treated in-hospital (OR: 5.15; 95%CI: 4.59-5.77), patients admitted to the ICU (OR: 10.48; 95%CI: 8.82-12.45), patients treated with systemic glucocorticoids (OR: 3.60; 95%CI: 3.21-4.03) and vasopressors (OR: 2.10; 95%CI: 1.60-2.75), and patients who received invasive mechanical ventilation (OR: 2.37; 95%CI: 1.82-3.09) were more likely to receive a systemic antibiotic. Most of the patients diagnosed with COVID-19 received antibiotics, despite evidence showing that bacterial coinfection is rare. Antibiotics from the Watch group predominated, a practice that goes against WHO recommendations.

The Impact of Antibiotic Use on Mortality in Patients Hospitalized in a COVID-19 Centre from Romania: A Retrospective Study

Background and Objectives: Considering the significant number of patients worldwide that received empirical antibiotic therapy for COVID-19 infection due to their critical condition and the lack of therapeutical guidelines, we wanted to find out the consequences of antibiotic use in our study population. Materials and Methods: We conducted a retrospective cohort study including symptomatic patients older than 18 years, hospitalized for SARS-CoV-2 between March and December 2020 in the Internal Medicine and Pneumology Departments of Colentina Clinical Hospital. The elected outcome was death, while independent variables were antibiotic therapy and literature-cited parameters associated with mortality in this disease. Results: Out of 198 included patients, 96 (48.48%) patients received antibiotic therapy during hospitalization. Female gender (OR = 2.61, p = 0.04), history of neoplasm (OR = 7.147, p = 0.01), heart failure (OR = 8.62, p = 0.002), and diabetes mellitus (OR = 3.05, p = 0.02) were significantly associated with death in multivariate analysis. Antibiotic treatment showed a higher probability of death both in bivariate (OR = 5.333, p < 0.001) and multivariate analysis adjusted for the aforementioned prognostic factors (OR = 3.55, p = 0.01). Conclusions: After adjusting for confounders, in-hospital antibiotic administration did not improve survival in COVID-19 patients.

Current Treatments for COVID-19: Application of Supercritical Fluids in the Manufacturing of Oral and Pulmonary Formulations

Even though more than two years have passed since the emergence of COVID-19, the research for novel or repositioned medicines from a natural source or chemically synthesized is still an unmet clinical need. In this review, the application of supercritical fluids to the development of novel or repurposed medicines for COVID-19 and their secondary bacterial complications will be discussed. We envision three main applications of the supercritical fluids in this field: (i) drug micronization, (ii) supercritical fluid extraction of bioactives and (iii) sterilization. The supercritical fluids micronization techniques can help to improve the aqueous solubility and oral bioavailability of drugs, and consequently, the need for lower doses to elicit the same pharmacological effects can result in the reduction in the dose administered and adverse effects. In addition, micronization between 1 and 5 µm can aid in the manufacturing of pulmonary formulations to target the drug directly to the lung. Supercritical fluids also have enormous potential in the extraction of natural bioactive compounds, which have shown remarkable efficacy against COVID-19. Finally, the successful application of supercritical fluids in the inactivation of viruses opens up an opportunity for their application in drug sterilization and in the healthcare field.

TiO2 based Photocatalysis membranes: An efficient strategy for pharmaceutical mineralization

Among the various emerging contaminants, pharmaceuticals (PhACs) seem to have adverse effects on the quality of water. Even the smallest concentration of PhACs in ground water and drinking water is harmful to humans and aquatic species. Among all the deaths reported due to COVID-19, the mortality rate was higher for those patients who consumed antibiotics. Consequently, PhAC in water is a serious concern and their removal needs immediate attention. This study has focused on the PhACs' degradation by collaborating photocatalysis with membrane filtration. TiO₂-based photocatalytic membrane is an innovative strategy which demonstrates mineralization of PhACs as a safer option. To highlight the same, an emphasis on the preparation and reinforcing properties of TiO₂-based nanomembranes has been elaborated in this review. Further, mineralization of antibiotics or cytostatic compounds and their degradation mechanisms is also highlighted using TiO₂ assisted membrane photocatalysis. Experimental reactor configurations have been discussed for commercial implementation of photoreactors for PhAC degradation anchored photocatalytic nanomembranes. Challenges and future perspectives are emphasized in order to design a nanomembrane based prototype in future for wastewater management.

A Formative Assessment of Antibiotic Dispensing/Prescribing Practices and Knowledge and Perceptions of Antimicrobial Resistance (AMR) among Healthcare Workers in Lahore Pakistan

(1) Background: Antimicrobial resistance causes significant disease burden in low- and middle-income countries. The objective of this paper is to describe antibiotic dispensing/prescribing practices and underlying factors associated with these practices among community-based healthcare workers. (2) Methods: Cross-sectional survey data were collected from private and public health facilities in 14 union councils, Lahore Pakistan. Respondents included physicians, nurses, lady health workers/volunteers, midwives, pharmacy and medicine shop employees, and medical technicians. Descriptive and bivariate analysis are used to present the data; (3) Results: 177 respondents completed the survey. In terms of weekly dispensing of antibiotics, the most common were Amoxicillin/Augmentin (2.3 [SD 1.5]), Cefixine (2.4 [SD 1.6]), and Azithromycin (2.5 [SD 2.1]). For children, antibiotics were more likely to be prescribed/dispensed for sore throat (54.3%/95) and diarrhea (48.9%/86). For adults, antibiotics were more likely to be prescribed/dispensed for sore throat (67.0%/118), diarrhea (59.7%/105) and burning sensation when urinating (55.7%/176). In total, 55.4% of respondents stated that they have sold partial antibiotic courses to patients/customers. A total of 44.6% of respondents incorrectly answered that antibiotics could be used for viral infections; (4) Conclusions: Data from this study and similar research emphasize the urgent need to implement community-based stewardship programs for all healthcare workers.

Discerning the role of polymyxin B nonapeptide in restoring the antibacterial activity of azithromycin against antibiotic-resistant Escherichia coli

Antimicrobial resistance is a global public health threat. Antibiotic development pipeline has few new drugs; therefore, using antibiotic adjuvants has been envisioned as a successful method to preserve existing medications to fight multidrug-resistant (MDR) pathogens. In this study, we investigated the synergistic effect of a polymyxin derivative known as polymyxin B nonapeptide (PMBN) with azithromycin (AZT). A total of 54 Escherichia coli strains were first characterized for macrolide resistance genes, and susceptibility to different antibiotics, including AZT. A subset of 24 strains was then selected for synergy testing by the checkerboard assay. PMBN was able to re-sensitize the bacteria to AZT, even in strains with high minimum inhibitory concentrations (MIC: 32 to ≥128 μg/ml) for AZT, and in strains resistant to the last resort drugs such as colistin and meropenem. The fractional inhibitory concentration index was lower than 0.5, demonstrating that PMBN and AZT combinations had a synergistic effect. The combinations worked efficiently in strains carrying mphA gene encoding macrolide phosphotransferase which can cause macrolide inactivation. However, the combinations were inactive in strains having an additional ermB gene encoding macrolide methylase which causes ribosomal drug target alteration. Killing kinetics study showed a significant reduction of bacterial growth after 6 h of treatment with complete killing achieved after 24 h. Transmission electron microscopy showed morphological alterations in the bacteria treated with PMBN alone or in combination with AZT, with evidence of damage to the outer membrane. These results suggested that PMBN acted by increasing the permeability of bacterial outer membrane to AZT, which was also evident using a fluorometric assay. Using multiple antimicrobial agents could therefore be a promising strategy in the eradication of MDR bacteria. PMBN is a good candidate for use with other antibiotics to potentiate their activity, but further studies are required in vivo. This will significantly contribute to resolving antimicrobial resistance crisis.

Antibiotic Use among Patients Hospitalized with COVID-19 and Treated in Three Different Clinics

Objective

In this study, we aimed to determine and compare the rates of empirical antibiotic use and duration between the chest diseases clinic (CDC), infectious disease clinic (IDC), and internal medicine clinic (IMC) among patients hospitalized because of COVID-19.

Methods

This cross-sectional study was performed in a single university hospital. The study included all patients aged 18 years and older hospitalized with a PCR-confirmed COVID-19 between May 30, 2021, and August 30, 2021. Clinical and laboratory findings were recorded from the electronic medical records database.

Results

The study included a total of 581 inpatients, of whom 310 (53.4%) were women. Of the 581 patients, 475 (81.8%) were prescribed antibiotics. The rate of antibiotic prescription was 71.6% for IDC, 88.5% for CDC, and 87.4% for IMC. The most commonly used antibiotic was moxifloxacin in all groups. The mean treatment duration was 8.9±6.16 days. The mean duration of antibiotic treatment was 11.1±5.90 days for CDC, 11.3±6.74 days for IMC, and 5.3 days±3.76 for IDC.

Conclusion

Patients with COVID-19 who were treated in IDC had a lower rate and shorter duration of antibiotic use compared to the other clinics. However, the rate of antibiotic prescription in all three groups was very high. Therefore, antimicrobial management programs should be meticulously conducted to reduce unnecessary antibiotic use.

Gomes AB, Matheus VA, Antunes ASLM, Crunfli F, Antunes KH, de Souza APD, Consonni SR, Leiria LO, Alves-Filho JC, Cunha TM, Moraes-Vieira PMM, Proença-Módena JL, R. Vinolo MA. Impact of Microbiota Depletion by Antibiotics on SARS-CoV-2 Infection of K18-hACE2 Mice

Clinical and experimental data indicate that severe acute respiratory syndrome coronavirus (SARS-CoV)-2 infection is associated with significant changes in the composition and function of intestinal microbiota. However, the relevance of these effects for SARS-CoV-2 pathophysiology is unknown. In this study, we analyzed the impact of microbiota depletion after antibiotic treatment on the clinical and immunological responses of K18-hACE2 mice to SARS-CoV-2 infection. Mice were treated with a combination of antibiotics (kanamycin, gentamicin, metronidazole, vancomycin, and colistin, Abx) for 3 days, and 24 h later, they were infected with SARS-CoV-2 B lineage. Here, we show that more than 80% of mice succumbed to infection by day 11 post-infection. Treatment with Abx had no impact on mortality. However, Abx-treated mice presented better clinical symptoms, with similar weight loss between infected-treated and non-treated groups. We observed no differences in lung and colon histopathological scores or lung, colon, heart, brain and kidney viral load between groups on day 5 of infection. Despite some minor differences in the expression of antiviral and inflammatory markers in the lungs and colon, no robust change was observed in Abx-treated mice. Together, these findings indicate that microbiota depletion has no impact on SARS-CoV-2 infection in mice.

Outpatient Antibiotic and Antiviral Utilization Patterns in Patients Tested for Respiratory Pathogens in the United States: A Real-World Database Study

This retrospective observational study evaluated outpatient treatment patterns among patients with molecular-based viral diagnostic testing for suspected upper respiratory tract infections in the United States. Patients with a respiratory viral test were identified from 1 August 2016 to 1 July 2019 in a large national reference laboratory database linked to IQVIA's prescription and medical claims databases. Antibiotic and influenza antiviral treatment patterns were reported up to 7 days post-test result. Predictors of antibiotic utilization were assessed using multivariable logistic regression. Among 9561 patients included in the study, 24.6% had evidence of ≥1 filled antibiotic prescription. Antibiotic utilization was higher in patients who tested negative for all viral targets (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.17-1.50) and patients positive for non-influenza viruses (OR, 1.28; 95% CI, 1.09-1.51) compared with those influenza-positive only. Age ≥ 50 years and location outside of the northeast United States also predicted antibiotic utilization. Influenza antivirals were more common in influenza-positive patients compared with patients with other test results (32.5% vs. 3.6-9.0%). Thus, in this real-world study, antibiotic utilization was elevated in patients positive for non-influenza viruses, although antibiotics would generally not be indicated. Further research on pairing diagnostic tools with outpatient antibiotic stewardship programs is needed.

Differences in clinical features and mortality in very old unvaccinated patients (≥ 80 years) hospitalized with COVID-19 during the first and successive waves from the multicenter SEMI-COVID-19 Registry (Spain)

BACKGROUND

Old age is one of the most important risk factors for severe COVID-19. Few studies have analyzed changes in the clinical characteristics and prognosis of COVID-19 among older adults before the availability of vaccines. This work analyzes differences in clinical features and mortality in unvaccinated very old adults during the first and successive COVID-19 waves in Spain.

METHODS

This nationwide, multicenter, retrospective cohort study analyzes unvaccinated patients ≥ 80 years hospitalized for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). Patients were classified according to whether they were admitted in the first wave (March 1-June 30, 2020) or successive waves (July 1-December 31, 2020). The endpoint was all-cause in-hospital mortality, expressed as the case fatality rate (CFR).

RESULTS

Of the 21,461 patients hospitalized with COVID-19, 5,953 (27.7%) were ≥ 80 years (mean age [IQR]: 85.6 [82.3-89.2] years). Of them, 4,545 (76.3%) were admitted during the first wave and 1,408 (23.7%) during successive waves. Patients hospitalized in successive waves were older, had a greater Charlson Comorbidity Index and dependency, less cough and fever, and met fewer severity criteria at admission (qSOFA index, PO2/FiO2 ratio, inflammatory parameters). Significant differences were observed in treatments used in the first (greater use of antimalarials, lopinavir, and macrolides) and successive waves (greater use of corticosteroids, tocilizumab and remdesivir). In-hospital complications, especially acute respiratory distress syndrome and pneumonia, were less frequent in patients hospitalized in successive waves, except for heart failure. The CFR was significantly higher in the first wave (44.1% vs. 33.3%; -10.8%; p < 0.001) and was higher among patients ≥ 95 years (54.4% vs. 38.5%; -15.9%; p < 0.001). After adjustments to the model, the probability of death was 33% lower in successive waves (OR: 0.67; 95% CI: 0.57-0.79).

CONCLUSIONS

Mortality declined significantly between the first and successive waves in very old unvaccinated patients hospitalized with COVID-19 in Spain. This decline could be explained by a greater availability of hospital resources and more effective treatments as the pandemic progressed, although other factors such as changes in SARS-CoV-2 virulence cannot be ruled out.

Factors Associated with Length of Hospital Stay among COVID-19 Patients in Saudi Arabia: A Retrospective Study during the First Pandemic Wave

The COVID-19 pandemic severely affected healthcare systems and tested their preparedness. To date, the length of hospital stay (LoHS) and its factors among COVID-19 patients has not been thoroughly studied. Moreover, it is essential to identify the features of these patients. Adult COVID-19 patients in Saudi Arabia with complete electronic medical records and who were hospitalised for >1 day between 1 May 2020 and 30 July 2020 at one of two hospitals were considered for this retrospective cohort study. Descriptive statistics and multivariate generalized linear models were performed using the data. Of the patients, 34% were ≥50 years old and 80.14% were female. More than 70% had mild-to-moderate symptoms; 45% had either diabetes or hypertension. The median LoHS was 7.00 days (IQR: 3−11). Patients who were females, had either critical or severe disease, were on mechanical ventilation, had diabetes, and administered ceftriaxone had significantly longer LoHS (p < 0.05). Patients administered zinc sulphate had significantly shorter LoHS (p = 0.0008). During the first pandemic wave, COVID-19 patients were hospitalised for 7 days. Healthcare professionals should pay more attention to women, patients with diabetes, and those with severe or critical symptoms. Unnecessary use of ceftriaxone should be minimised, and zinc sulphate can be administered.

Decreased survival in children inpatients with COVID-19 and antibiotic prescription

Background

The empirical prescription of antibiotics to inpatients with Coronavirus Disease 2019 (COVID-19) is frequent despite uncommon bacterial coinfections. Current knowledge of the effect of antibiotics on the survival of hospitalized children with COVID-19 is limited.

Objective

To characterize the survival experience of children with laboratory-positive COVID-19 in whom antibiotics were prescribed at hospital admission.

Methods

A retrospective cohort study was conducted in Mexico, with children hospitalized due to COVID-19 from March 2020 to December 2021. Data from 1601 patients were analyzed using the Kaplan–Meier method and the log-rank test. We computed hazard ratios (HR) and 95% confidence intervals (CI) to evaluate the effect of the analyzed exposures on disease outcomes.

Results

Antibiotics were prescribed to 13.2% (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$n$$\end{document}n = 211) of enrolled children and a higher mortality rate [14.9 (95% CI 10.1–19.8) vs. 8.3 (95% CI 6.8–9.8)] per 1000 person-days, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p$$\end{document}p < 0.001) was found among them. At any given cut-off, survival functions were lower in antibiotic-positive inpatients (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$p$$\end{document}p < 0.001). In the multiple model, antibiotic prescription was associated with a 50% increase in the risk of fatal outcome (HR = 1.50, 95% CI 1.01–2.22). A longer interval between illness onset and healthcare-seeking and pneumonia at hospital admission was associated with a poorer prognosis.

Conclusions

Our results suggest that antibiotic prescription in children hospitalized due to COVID-19 is associated with decreased survival. If later replicated, these findings highlight the need for rational antibiotics in these patients.

Prior use of antibiotics and immunosuppression are risk factors for fracture-related infection during the COVID-19 pandemic period: a Brazilian prospective cohort study

Background

Little is known about the role of COVID-19 pandemic period on the epidemiology of fracture-related infection (FRI). The present study summarizes the changes in the prevalence, microbiology, and risk factors of FRI during this period.

Methods

A prospective single-center cohort study assessed in the setting of COVID-19 pandemic (2020–2021), clinical, microbiological aspects, and independent risk factors (RF) of FRI. RFs were estimated by bivariate and multivariable analyses using prevalence ratio (PR) with significance at P < 0.05. Kaplan–Meier analysis was performed to evaluate treatment outcomes.

Results

Overall, 132 patients were analyzed, with patients with age over 65 years accounting 65.1%. FRI was diagnosed in 21(15.9%) patients. Independent RFs for FRI were recent and preoperative use of systemic antibiotics (PR: 7.0, 95% confidence interval (95% CI): 2.2 – 22.4, p = 0.001) and cancer (PR: 9.8, 95% CI: 2.0 – 48.8, p = 0.005). Cultures yielded Gram-negative bacteria in 77.8%, 33.3% were MDR.

Conclusions

We found higher rates of FRI, predominating in the elderly with closed femoral fractures during the COVID-19 pandemic. Prior use of antibiotics and immunosuppression conditions were independent factor for FRI. Our outcomes provide evidence to avoid the empirical use of antibiotics prior to surgery for fracture stabilization.

In-Hospital Antibiotic Use for COVID-19: Facts and Rationales Assessed through a Mixed-Methods Study

It is well known that during the coronavirus disease 2019 (COVID-19) pandemic, antibiotics were overprescribed. However, less is known regarding the arguments that have led to this overuse. Our aim was to understand the factors associated with in-hospital antibiotic prescription for COVID-19, and the rationale behind it. We chose a convergent design for this mixed-methods study. Quantitative data was prospectively obtained from 533 adult patients admitted in six hospitals (services of internal medicine, infectious diseases and pneumology). Fifty-six percent of the patients received antibiotics. The qualitative data was obtained from interviewing 14 physicians active in the same departments in which the enrolled patients were hospitalized. Thematic analysis was used for the qualitative approach. Our study revealed that doctors based their decisions to prescribe antibiotics on a complex interplay of factors regarding the simultaneous appearance of consolidation on the chest computer tomography together with a worsening of clinical conditions suggestive of bacterial infection and/or an increase in inflammatory markers. Besides these features which might suggest bacterial co-/suprainfection, doctors also prescribed antibiotics in situations of uncertainty, in patients with severe disease, or with multiple associated comorbidities.

Empirical Antibiotic Prescribing in Adult COVID-19 Inpatients over Two Years in Mexico

Background and Objectives: Empirical antibiotic prescribing in patients with coronavirus disease 2019 (COVID-19) has been common even though bacterial coinfections are infrequent. The overuse of antibacterial agents may accelerate the antibiotic resistance crisis. We aimed to evaluate factors predicting empirical antibiotic prescribing to adult COVID-19 inpatients over 2 years (March 2020–February 2021) in Mexico. Materials and Methods: A cross-sectional analysis of a nationwide cohort study was conducted. Hospitalized adults due to laboratory-confirmed COVID-19 were included (n = 214,171). Odds ratios (OR) and 95% confidence intervals (CI), computed by using logistic regression models, were used to evaluate factors predicting empirical antibiotic prescribing. Results: The overall frequency of antibiotic usage was 25.3%. In multiple analysis, the highest risk of antibiotic prescription was documented among patients with pneumonia at hospital admission (OR = 2.20, 95% CI 2.16–2.25). Male patients, those with chronic comorbidities (namely obesity and chronic kidney disease) and longer interval days from symptoms onset to healthcare seeking, were also more likely to receive these drugs. We also documented that, per each elapsed week during the study period, the odds of receiving antibiotic therapy decreased by about 2% (OR = 0.98, 95% CI 0.97–0.99). Conclusion: Our study identified COVID-19 populations at increased risk of receiving empirical antibiotic therapy during the first two years of the pandemic.

COVID-19 Autopsies Reveal Underreporting of SARS-CoV-2 Infection and Scarcity of Co-infections

Coronavirus disease 2019 (COVID-19) mortality can be estimated based on reliable mortality data. Variable testing procedures and heterogeneous disease course suggest that a substantial number of COVID-19 deaths is undetected. To address this question, we screened an unselected autopsy cohort for the presence of SARS-CoV-2 and a panel of common respiratory pathogens. Lung tissues from 62 consecutive autopsies, conducted during the first and second COVID-19 pandemic waves in Switzerland, were analyzed for bacterial, viral and fungal respiratory pathogens including SARS-CoV-2. SARS-CoV-2 was detected in 28 lungs of 62 deceased patients (45%), although only 18 patients (29%) were reported to have COVID-19 at the time of death. In 23 patients (37% of all), the clinical cause of death and/or autopsy findings together with the presence of SARS-CoV-2 suggested death due to COVID-19. Our autopsy results reveal a 16% higher SARS-CoV-2 infection rate and an 8% higher SARS-CoV-2 related mortality rate than reported by clinicians before death. The majority of SARS-CoV-2 infected patients (75%) did not suffer from respiratory co-infections, as long as they were treated with antibiotics. In the lungs of 5 patients (8% of all), SARS-CoV-2 was found, yet without typical clinical and/or autopsy findings. Our findings suggest that underreporting of COVID-19 contributes substantially to excess mortality. The small percentage of co-infections in SARS-CoV-2 positive patients who died with typical COVID-19 symptoms strongly suggests that the majority of SARS-CoV-2 infected patients died from and not with the virus.

Inappropriate Antibiotic Use in Zimbabwe in the COVID-19 Era: A Perfect Recipe for Antimicrobial Resistance

The global COVID-19 pandemic has resulted in an upsurge in antimicrobial use. The increase in use is multifactorial, and is particularly related to the empirical treatment of SARS-CoV-2 and suspected coinfections with antimicrobials and the limited quality of diagnostics to differentiate viral and bacterial pneumonia. The lack of clear clinical guidelines across a wide range of settings, and the inadequacy of public health sectors in many countries, have contributed to this pattern. The increased use of antimicrobials has the potential to increase incidences of antimicrobial resistance, especially in low-resource countries such as Zimbabwe already grappling with multidrug-resistant micro-organism strains. By adopting the antimicrobial stewardship principles of the correct prescription and optimised use of antimicrobials, as well as diagnostic stewardship, revamping regulatory oversight of antimicrobial surveillance may help limit the occurrence of antimicrobial resistance during this pandemic.

The landscape of antibiotic usage among COVID-19 patients in the early phase of pandemic: a Malaysian national perspective

Background

During the early phase of the COVID-19 pandemic, antibiotic usage among COVID-19 patients was noted to be high in many countries. The objective of this study was to determine the prevalence of antibiotic usage and factors affecting antibiotic usage among COVID-19 patients during the early phase of the COVID-19 pandemic in Malaysia.

Methods

This was a cross-sectional study that involved reviewing medical records of COVID-19 Malaysian patients aged 12 and above who were diagnosed with COVID-19 and received treatment in 18 COVID-19 hospitals from February to April 2020. A minimum sample of 375 patients was required. A binary logistic regression analysis was performed to determine factors associated with antibiotic usage. Variables with p < 0.05 were considered statistically significant.

Results

A total of 4043 cases were included for analysis. The majority of the patients (87.6%) were non-smokers, male (65.0%), and had at least one comorbidity (37.0%). The median age was 35 years (IQR: 38). The prevalence of antibiotic usage was 17.1%, with 5.5% of them being prescribed with two or more types of antibiotics. The most frequent antibiotics prescribed were amoxicillin/clavulanic acid (37.8%), ceftriaxone (12.3%), piperacillin/tazobactam (13.3%), azithromycin (8.3%), and meropenem (7.0%). Male patients (adjusted OR 1.53), who had a comorbidity (adjusted OR 1.36), associated with more severe stage of COVID-19 (adjusted OR 6.50–37.06), out-of-normal range inflammatory blood parameters for neutrophils, lymphocytes, and C-reactive protein (adjusted OR 2.04–3.93), corticosteroid use (adjusted OR 3.05), and ICU/HDU admission (adjusted OR 2.73) had higher odds of antibiotic use.

Conclusions

The prevalence of antibiotic usage in the early phase of the COVID-19 pandemic was low, with amoxicillin/clavulanic acid as the most common antibiotic of choice. The study showed that clinicians rationalized antibiotic usage based on clinical assessment, supported by relevant laboratory parameters.

Treatment paradigms in Parkinson's Disease and Covid-19

People with Parkinson's Disease (PwP) may be at higher risk for complications from the Coronavirus Disease 2019 (Covid-19) due to older age and to the multi-faceted nature of Parkinson's Disease (PD) per se, presenting with a variety of motor and non-motor symptoms. Those on advanced therapies may be particularly vulnerable. Taking the above into consideration, along with the potential multi-systemic impact of Covid-19 on affected patients and the complications of hospitalization, we are providing an evidence-based guidance to ensure a high standard of care for PwP affected by Covid-19 with varying severity of the condition. Adherence to the dopaminergic medication of PwP, without abrupt modifications in dosage and frequency, is of utmost importance, while potential interactions with newly introduced drugs should always be considered. Treating physicians should be cautious to acknowledge and timely address any potential complications, while consultation by a neurologist, preferably with special knowledge on movement disorders, is advised for patients admitted in non-neurological wards. Non-pharmacological approaches, including the patient's mobilization, falls prevention, good sleep hygiene, emotional support, and adequate nutritional and fluid intake, are essential and the role of telemedicine services should be strengthened and encouraged.