High Antimicrobial Use Seen in COVID Patients During First Wave

Peter Russell

June 03, 2021

Use of antimicrobials among COVID-19 patients should be assisted by clear guidelines to reduce the risk of drug-resistance, experts said.

A study in The Lancet Microbe journal found that although bacterial infections among patients in hospital with COVID were rare during the first wave of the pandemic, antimicrobial use was common.

A research team, led by the University of Glasgow, said antimicrobial prescriptions, particularly to newly hospitalised patients, should be restricted until tests confirmed a bacterial infection.

'Precious' Antibiotics

Co-author Calum Semple, professor in child health and outbreak medicine at the University of Liverpool, explained at a briefing hosted by the Science Media Centre: "It's not uncommon for viral diseases to be complicated by bacterial infection, but we're not seeing that very much. 

"We're seeing rather more antibiotics being used than we would like. We're also seeing the most precious antibiotics being used that we would like to reserve for serious bacterial infections."

Dr Antonia Ho, clinical senior lecturer at the University of Glasgow, said: "Since antimicrobial resistance remains one of the biggest public health challenges of our time, measures to combat it are essential to help ensure that these life-saving medicines remain an effective treatment for infection in years to come."
 

Observational Study

The study identified bacterial infections, types of bacteria identified, the number of people prescribed antimicrobials, and the types of antimicrobials prescribed among 48,902 patients admitted to 260 hospitals in England, Scotland, and Wales due to COVID-19 between February 6 and June 8, 2020. 

Patients had a median age of 74.

The timing of infection was recorded either as occurring prior to hospitalisation or after admission. Microbiological tests were recorded for 17·7% of patients.

When bacterial infections were detected in COVID-19 patients, 70.6% were secondary infections, acquired more than 2 days after patients were admitted to hospital. Staphylococcus aureus and Haemophilus influenzae were the most common causes of respiratory co-infections, while Enterobacteriaceae and S aureus were the most common in secondary respiratory infections

Bloodstream infections were most often caused by Escherichia coli and S aureus.

Where data was available, 37% of patients had been prescribed antimicrobials before being admitted to hospital, while 85% received one or more antimicrobials at some point during their hospital stay.

Broad-spectrum antimicrobials, such as carbapenems, were used frequently, accounting for 3.8% of all prescriptions. In contrast, carbapenem-sparing alternatives were used less often, accounting for between 0.2% and 1.5% of all prescriptions. 
 

Antimicrobial Stewardship

The study authors said that antimicrobial stewardship interventions should be incorporated into care for patients with COVID, particularly when tests ruled out bacterial infection or when it was unlikely that bacterial infection had occurred before hospitalisation.

"We think that the patterns of antimicrobial usage seen are concerning, and we worry that that might in the future lead to an increase in antimicrobial resistance," said Dr Clark Russell, a clinical lecturer in infectious diseases at the University of Edinburgh, who co-authored the paper.

He advocated a "more restrictive approach to usage", while "microbiology samples should be obtained, ideally before giving a person antimicrobials", and that "routine escalation to a broad spectrum antimicrobial should be avoided, especially in critical care".

Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. The Lancet Microbe. DOI:https://doi.org/10.1016/S2666-5247(21)00090-2

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