Journals | Policy | Permission

This journal has moved to cii.elmerpub.com Please go to the new site to make submissions

Clinical Infection & Immunity

Editorial

Volume 6, Number 2, June 2021, pages 29-30

Parsimonious Use of Antibiotics in COVID-19: A Missed Opportunity

Patients with coronavirus disease 2019 (COVID-19) are often treated with antibiotics. A recent survey in the context of the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), including > 240,000 hospitalized COVID-19 patients, revealed that 80.7% of them received antibiotics [1]. This rate went up to over 90% of cases when intensive care unit (ICU) patients were considered [1].

Overuse of antibiotics in COVID-19 may be due to several reasons: 1) absence of a definite diagnosis of viral pneumonia in the early phases of the disease before severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection diagnosis; 2) fear that viral pneumonia may be complicated by a bacterial superinfection; 3) sparse but strongly believed data suggesting some antibiotics, including azithromycin, might have a favorable effect on COVID-19 clinical course [2]. The end result is a possibly important rise of selective pressures on the microbial flora that could, in theory, have detrimental effects on individual patients and negatively impact effectiveness of use of antimicrobials for other appropriate indications. Also, the widespread use of antibiotics could further fuel incidence of infections due to multi-drug resistant (MDR) microrganisms.

As far as we know, little data exist on the efficacy of antibiotics in COVID-19. In a Korean study on 6,871 hospitalized patients, 35% had received an antibiotic and 22% received molecules active on Staphylococcus aureus and Pseudomonas aeruginosa, without effects on outcomes [3]. Investigators called for a better understanding of the role of antibiotics in COVID-19, to prevent antimicrobial overuse. In a systematic review and meta-analysis on > 3,800 patients, a low proportion of COVID-19 patients had a documented bacterial co-infection, supporting a parsimonious use of antibiotics in COVID-19 should be pursued [4]. In a commenting letter to this paper, early administered antibiotics were not found to impact mortality in critically ill patients with COVID-19 [5]. Indeed, in the ISARIC cohort, despite of a high rate of microbiological tests performed, only a minority of cases (about 10%) showed positive bacterial cultures [1].

In addition to the lack of evidence of antibiotic indication or effectiveness in COVID-19, antibiotic misuse can increase the risk for MDR bacterial infections in severe or critical COVID-19 patients with a prolonged hospital stay. We recently observed that in a cohort of COVID-19 patients hospitalized in the ICU, a large proportion (50%) developed infections due to MDR or extensively drug-resistant (XDR) microrganisms [6].

As a matter of fact, no randomized or controlled clinical trials have been performed that were aimed at assessing the role of antibiotics in COVID-19. Certainly, it would be of great usefulness to further understand the effect of antibiotics in patients with COVID-19, even starting from scrutiny of observational data. However, it should be considered that as the majority of patients receive antibiotics, it could not be feasible to draw meaningful comparisons between the latter and the few patients who did not receive antibiotics.

At present, no study has shown that antibiotic therapy improves hospital mortality or rate of complications in COVID-19. Neither any study has assessed whether antibiotics, taken before clinical worsening occurs, reduce the rate of ICU admission. Indeed, a specific concern is the possibility that specific antibiotic molecules, including but not limited to azithromycin, could indeed exert negative effects on mortality. Ideally, a prospective randomized clinical study including patients treated with or without antibiotics should be carried on.

Several other questions remain open. Which would be the rate of bacterial coinfections in COVID-19 if an active systematic screening, including lower respiratory tract sampling, would be performed? Is there a direct association between antibiotic use and superinfection with MDR/XDR bacteria or fungi? Finally, could a common marker of bacterial infection, such as procalcitonin, be used as a guide for antibiotic use in COVID-19? Answers to these questions will certainly improve our understanding of COVID-19 and our ability to successfully care for these patients.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Data Availability

The author declares that data supporting the findings of this study are available within the article.

1. Escher M, Hall M, Baillie JK, Baruch J, Blumberg L, Carson G, et al. ISARIC Clinical Data Report 10 February 2021. International Severe Acute Respiratory and emerging Infections Consortium. MedRxiv. Preprint posted February 11, 2021.
   doi
2. Oldenburg CE, Doan T. Azithromycin for severe COVID-19. Lancet. 2020;396(10256):936-937.
   doi
3. Shin DH, Kang M, Song KH, Jung J, Kim ES, Kim HB. A call for antimicrobial stewardship in patients with COVID-19: a nationwide cohort study in Korea. Clin Microbiol Infect. 2021;27(4):653-655.
   doi pubmed
4. Lansbury L, Lim B, Baskaran V, Lim WS. Co-infections in people with COVID-19: a systematic review and meta-analysis. J Infect. 2020;81(2):266-275.
   doi pubmed
5. Buetti N, Mazzuchelli T, Lo Priore E, Balmelli C, Llamas M, Pallanza M, Elzi L, et al. Early administered antibiotics do not impact mortality in critically ill patients with COVID-19. J Infect. 2020;81(2):e148-e149.
   doi pubmed
6. Karruli A, Boccia F, Gagliardi M, Patauner F, Ursi MP, Sommese P, De Rosa R, et al. Multidrug-resistant infections and outcome of critically ill patients with coronavirus disease 2019: a single center experience. Microb Drug Resist. 2021.
   doi pubmed

This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Clinical Infection and Immunity is published by Elmer Press Inc.