Experts lay out antibiotic stewardship lessons from COVID-19

IV drip at patient's bedside
IV drip at patient's bedside

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A panel of experts with the Society for Healthcare Epidemiology of America (SHEA) published a statement last week on ways to improve antibiotic use and stewardship during infectious disease pandemics and outbreaks.

The statement, published in Infection Control & Hospital Epidemiology, addresses widespread inappropriate antibiotic use during the COVID-19 pandemic. The height of unnecessary antibiotic use took place in the early stages of the pandemic, when hospitals were flooded with severely ill patients, diagnostic tests were unavailable or took several days to return results, no treatments were available, and healthcare providers wanted to do something to help.

The situation has improved since then, with more reliable tests, quicker turnaround times, and established treatments reducing use of antibiotics in COVID-19 patients. In cases in which empiric antibiotics are prescribed because of concerns about bacterial coinfections, they are discontinued quickly.

Antibiotic initiation, however, has remained high, and there are concerns that antibiotic overprescribing in COVID-19 patients is one of the factors contributing to an increase in multidrug-resistant hospital infections.

But the statement is less a criticism of how antibiotics have been misused during the pandemic than an acknowledgement of the challenges posed by COVID-19 and providers' difficulty not using antibiotics in an environment of heightened illness and uncertainty. It's also an attempt to establish evidence-based guidelines for how the healthcare system and antibiotic stewardship programs (ASPs) should react during the next public health emergency caused by a viral respiratory disease, says the lead author.

"The point we were trying to make is that there are evidence-based principles that you can follow…and we think these principles can be applied to the next respiratory viral epidemic," Tamar Barlam, MD, director of Antimicrobial Stewardship at Boston Medical Center and chair of the SHEA Antimicrobial Stewardship Committee, told CIDRAP News.

'Low threshold' for antibiotic use

The high level of antibiotic use seen in the early months of the pandemic is certainly understandable, Barlam says. Hospitals were overwhelmed with severely ill patients sickened by a mysterious new respiratory illness, and little could be done for them. Clinicians desperately wanted to do something for these patients, many of whom presented as having bacterial pneumonia. There were also early media-fueled reports that the antibiotic azithromycin might be effective.

All these factors led to a "low threshold" for antibiotic initiation, Barlam and her colleagues write.

"If we can remember back to that point, there were no vaccines, there were no treatments. It wasn't clear if there was any role for any number of agents," she said. "And in many ways, giving an antibiotic is just easier than having to really think it through."

But even when testing became more reliable and patients were coming in with classic signs of COVID-19, prescribing antibiotics became an almost "knee jerk" reaction, with some patients receiving broad-spectrum drugs more appropriate for hospital-associated infections.

"To treat someone who was basically healthy until they got COVID as if they had a hospital-associated pneumonia…wasn't appropriate," Barlam said. "But we were seeing it all the time."

Another factor early in the pandemic, and one that has continued to drive antibiotic use in COVID-19 patients, is concern about bacterial coinfections, especially in older patients with other morbidities. But Barlam and her colleagues note that studies have shown that only 3.1% to 5.5% of COVID-19 patients have bacterial coinfections.

To prevent this type of antibiotic use in future viral respiratory outbreaks, the SHEA statement recommends first that healthcare providers limit initiation of antibiotics when there is a "high pre-test probability" for a viral infection, even in cases in which accurate diagnostics aren't readily available.

"There is no evidence that routine antibiotics are needed for respiratory viral pandemics in patients who do not exhibit clear signs of bacterial coinfection," the statement says.

The statement goes on to say that healthcare providers can perform inflammatory marker tests, such C-reactive protein or procalcitonin tests, but that those markers should not be used as the basis for initiation of antibiotics because they may not be indicative of a bacterial or fungal infection.

Barlam and her colleagues acknowledge that it's important for providers to identify patients who may require antibiotic initiation—such as those who have symptoms indicating bacterial pneumonia or another bacterial coinfection—and to follow with microbiologic testing to confirm the infection and adjust antibiotic therapy accordingly. But they warn against overuse of diagnostic tests when there are no signs of bacterial coinfection.

The role of stewardship

Finally, the SHEA statement emphasizes the important role that ASPs can play in future outbreaks or pandemics, not just in terms of developing treatment guidelines and monitoring appropriate antibiotic use. ASPs can also provide advice and support for clinicians in the face of clinical uncertainty and, as they have done during the COVID-19 pandemic, help evaluate and implement other treatment regimens.

"Stewardship is actually part of an emergency response," Barlam said.

Barlam knows that whenever a viral outbreak or pandemic occurs, the challenges seen during COVID will likely rear their head again. But she hopes that the statement clearly lays out the evidence-based steps that providers should take to minimize unnecessary antibiotic use in that event.

"I think we know that if there's another huge outbreak, that we are going to have to reinforce and reeducate and provide guidance," she said. "But it's always good to lay it out in a way that you have a common lexicon that you can work from."

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