Microbial Co-infection Uncommon With Coronavirus Infection

By Will Boggs MD

May 12, 2020

NEW YORK (Reuters Health) - Bacterial or fungal co-infection is uncommon in patients with SARS-CoV-2 or other coronavirus infections, according to a new review.

"Despite this, 72 in every 100 patients with COVID-19 receive antibiotics during their hospital admission," Dr. Alison Holmes of Hammersmith Hospital and Imperial College London told Reuters Health by email. "During the pandemic, hospitals should not lose sight of the need to maintain antibiotic stewardship activity, including optimizing antibiotic prescribing and the prevention of healthcare-associated infection."

The clinical presentation of patients with SARS-CoV-2 can be similar to that of atypical bacterial pneumonia, and many patients are treated empirically with antimicrobials. Whether this is appropriate remains unclear.

Dr. Holmes and colleagues explored commonly reported bacterial/fungal co-infections in patients admitted to hospital with coronavirus lower-respiratory-tract infections. Because of the paucity of data regarding SARS-CoV-2, the virus that causes COVID-19, they also included SARS, Middle Eastern Respiratory Syndrome (MERS), and other coronavirus infections.

In the nine available studies of COVID-19, 8% of patients had bacterial/fungal co-infection. It was unclear whether these patients were critically ill or not and whether the infections were nosocomial or acquired in the community.

In other coronavirus studies, 11% of patients had identified bacterial/fungal co-infection, the researchers report in Clinical Infectious Diseases.

Despite these modest rates of co-infection, 72% of patients with COVID-19 and 93% of patients infected with other coronaviruses received antibacterial therapy, which tended to be broad-spectrum and empiric.

Complications of antimicrobial therapy were not reported in any study.

"It is likely that rates of co-infection will differ across different areas of the hospital," Dr. Holmes said. "For example, there are some reports of higher rates of co-infection in patients who die of COVID-19 on intensive care. Whether this is due to COVID-19 or a consequence of prolonged critical illness remains unclear. It is likely that we will not know the true impact of COVID-19 and co-infection for several months."

"Antibiotics do not work on viral infections, and there are potential consequences related to their overuse, including side effects for patients, as well as the propagation of antimicrobial resistance and drug-resistant infection," she said.

"The challenge for clinicians is that the presentation to hospital with COVID-19 is very similar to bacterial infection, and we currently have very few ways of differentiating the two, as blood tests and X-rays may look similar," Dr. Holmes said. "Therefore, it is very difficult to suggest that clinicians avoid starting antibiotics when a patient is admitted."

"What we must do is focus on stopping inappropriate antibiotics early during the patient's admission," she said. "This requires appropriate diagnostic tests for all patients admitted with COVID-19 and the regular review of antibiotic prescriptions and stopping them when there is little evidence of bacterial co-infection."

"It will be important that further data is gathered as it emerges to support the optimal use of antimicrobial agents and to minimize the impact on antimicrobial resistance," she added.

SOURCE: https://bit.ly/3cgqJ5p Clinical Infectious Diseases, online May 2, 2020.