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Bacterial infection, antibiotic use and COVID-19: Lessons from the intensive care unit
M S Moolla1, K Reddy, I Fwemba
1Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa. saadiq.moolla@gmail.com.
Background:
Empirical broad-spectrum antibiotics are frequently prescribed to patients with severe COVID-19, motivated by concern about bacterial coinfection. There is no evidence of benefit from such a strategy, while the dangers of inappropriate antibiotics are well described.
Objectives:
To investigate the frequency, profile and related outcomes of infections by bacterial pathogens in patients admitted to an intensive care unit (ICU) with severe COVID-19 pneumonia.
Methods:
This was a prospective, descriptive study in a dedicated COVID-19 ICU in Cape Town, South Africa, involving all adult patients admitted to the ICU with confirmed COVID-19 pneumonia between 26 March and 31 August 2020. We collected data on patient comorbidities, laboratory results, antibiotic treatment, duration of admission and in-hospital outcome.
Results:
We included 363 patients, who collectively had 1 199 blood cultures, 308 tracheal aspirates and 317 urine cultures performed. We found positive cultures for pathogens in 20 patients (5.5%) within the first 48 hours of ICU admission, while 73 additional patients (20.1%) had positive cultures later during their stay. The most frequently isolated pathogens at all sites were Acinetobacter baumannii (n=54), Klebsiella species (n=13) and coagulase-negative staphylococci (n=9). Length of ICU stay (p<0.001) and intubation (p<0.001) were associated with positive cultures on multivariate analysis. Disease severity (p=0.5), early antibiotic use (p=0.5), diabetes mellitus (p=0.1) and HIV (p=0.9) were not associated with positive cultures. Positive cultures, particularly for tracheal aspirates (p<0.05), were associated with longer ICU length of stay and mortality. Early empirical antibiotic use was not associated with mortality (odds ratio 2.5; 95% confidence interval 0.95 - 6.81).
Conclusions:
Bacterial coinfection was uncommon in patients at the time of admission to the ICU with severe COVID-19. Avoiding early empirical antibiotic therapy is therefore reasonable. Strategies to avoid coinfection and outbreaks in hospital, such as infection prevention and control, as well as the strict use of personal protective equipment, are important to improve outcomes.
Insights
Bacterial coinfection is uncommon in severe COVID-19 patients admitted to the ICU. Avoiding early empirical antibiotic therapy is reasonable, as it does not improve outcomes and carries risks.
Area of Science:
- Infectious Diseases
- Critical Care Medicine
- Pulmonology
Background:
- Empirical broad-spectrum antibiotics are often given to severe COVID-19 patients due to concerns of bacterial coinfection.
- There is a lack of evidence supporting the benefit of this strategy.
- The risks associated with inappropriate antibiotic use are well-documented.
Purpose of the Study:
- To determine the frequency and profile of bacterial infections in intensive care unit (ICU) patients with severe COVID-19 pneumonia.
- To investigate the outcomes associated with these bacterial infections.
Main Methods:
- A prospective, descriptive study was conducted in a dedicated COVID-19 ICU in Cape Town, South Africa.
- Data were collected from adult patients admitted with confirmed COVID-19 pneumonia between March and August 2020.
- Information gathered included comorbidities, laboratory results, antibiotic treatment, and outcomes.
Main Results:
- Of 363 patients, 5.5% had positive cultures within 48 hours of ICU admission, and an additional 20.1% later in their stay.
- Acinetobacter baumannii was the most common pathogen, followed by Klebsiella species and coagulase-negative staphylococci.
- Positive cultures, especially from tracheal aspirates, correlated with longer ICU stays and increased mortality. Early antibiotic use did not significantly impact mortality.
Conclusions:
- Bacterial coinfection is infrequent upon ICU admission for severe COVID-19.
- Discontinuation of early empirical antibiotic therapy is a sensible approach.
- Implementing infection prevention and control measures is crucial for improving patient outcomes.
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