The Need for Antimicrobial Stewardship, HAI Infection Prevention During the COVID-19 Pandemic

Throughout the COVID-19 pandemic, patients hospitalized with the disease have had more to face than just the fight against COVID-19, as co-infection with drug-resistant pathogens has been shown to also contribute to rates of mortality and readmission, according to a webinar on Antimicrobial Stewardship and HAI [hospital-acquired infection], hosted by the American Hospital Association.

During the presentation, Kalvin Yu, MD, FIDSA, medical director of medical informatics at BD, explained that patients admitted to hospitals during the pandemic who tested positive for COVID-19 were found to have a higher mortality, longer length of stay, and higher rate of needing intensive care unit care than patients who tested negative for the virus.

“Ostensibly one could say that these clinical differences might reflect just different testing patterns. However, in a different analysis of the same dataset, which consisted of more than 1.8 million SARS-CoV-2 tested patients, we see that COVID-19-positive patients were cultured at a 97% rate, with a very close 92% rate for those who ended up negative,” Yu said during the webinar.

Yu explained that these rates make clinical sense, because those suspected of having COVID-19 can have similar symptoms to other diseases, such as bacterial pneumonia. For this reason, the cultures of patients suspected of having COVID-19 have been a tool in understanding all of the potential causes of patients’ symptoms and the complexity of the disease picture.

In a European study that analyzed the results of cultures of patients tested for COVID-19, 24% of patients who tested positive for the virus also tested positive for other respiratory pathogens, whereas only 15% of patients who tested negative for the virus tested positive for other respiratory pathogens.

“More cultures were also performed later in the hospitalization in COVID-19 patients, perhaps reflecting an added complexity to their clinical care compared to those who did not have COVID-19,” Yu said during the webinar.

In a similar study conducted by Johns Hopkins University on the prevalence of co-infection in COVID-19 patients, Yu explained that the researchers found 69% of patients with COVID-19 also received antibiotics for pneumonia during their stay, which is not a known treatment for COVID-19. The study had noted additionally that due to high use of empiric antibiotics, there was a clear need for stronger antibiotic stewardship in the treatment of viral pneumonias.

These findings were then closely mirrored in a study presented at the European Society for Clinical Microbiology and Infectious Diseases Conference on Corona Virus Disease (ECCVID), which demonstrated that 68% of COVID-19 patients were treated with antibiotics, whereas only 46% of patients who tested negative for COVID-19 were treated with antibiotics.

In this ECCVID study, the researchers also noted the antibiotics used for these treatments included extended spectrum third and fourth generation cephalosporins, macrolides, beta-lactamase inhibitors, vancomycin, and fluroquinolones and carbapenems.

“The antibiotics being used are also interesting,” Yu said during the webinar. “These are all drug-resistant agents that had resistance issues way before the pandemic. So, the question arises: What will be the effect on drug resistance overall if we are overusing, if you will, these drugs during a year-long-plus pandemic. Particularly now that scientists feel that there’s a possibility that COVID-19 will come back in a seasonal yearly fashion, what does this do to our arsenal of antimicrobial medication? Clearly there is an antimicrobial stewardship opportunity here.”

In an analysis published by the National Center for Biotechnology Information, the 5 most common respiratory pathogens in 152 patients with COVID-19 hospitalized during the New York City pandemic surge were found to be 44% staphylococcus aureus, 16% pseudomonas aeruginosa, 10% klebsiella spp, 8% enterobacter spp, and 4% escherichia coli.

Additionally, in a study published in the Annals of Internal Medicine on the 60-day outcomes of 1250 patients with COVID-19 after they were discharged from the hospital, 84 patients had died and 189 were readmitted to the hospital.

Yu noted that these rates are a common phenomenon among patients with multidrug resistant infections, as the CDC has found these patients have higher morbidity and higher mortality.

“But, for a new respiratory virus that we know little about, these statistics are similarly very sobering,” Yu said during the webinar.

In order to address these issues, Yu explained that the path of least resistance would be to use preexisting infrastructures to help, such as antimicrobial stewardship teams in order to facilitate appropriate and timely antimicrobial use and/or infection prevention programs to prevent infection spread and monitor HAIs.

“The stewardship and infection prevention programs also make sense from a regulatory standpoint, as the joint commission has long supported, reviewed, and dissected infection prevention programs in their licensing audit surveys,” Yu said during the webinar. “So, we do indeed have some clinical and regulatory-based logic to involve stewardship and infection prevention teams to help mitigate COVID-19 outcomes.”

REFERENCE

Yu K, Stenehjem EA, Moehring R. Antimicrobial Stewardship and HAI Infection Prevention: Insights from COVID-19. Presented at: American Hospital Association webinar; February 25, 2021; virtual. https://www.aha.org/center/performance-improvement/team-training/webinars/library?utm_source=eblast&utm_medium=email&utm_campaign=AHA%20Team%20Training:%20BD%20Webinar%20Follow-Up. Accessed March 1, 2021.