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Antibiotic Use, Bacterial Co-Infection, and Antimicrobial Resistance in Adults Hospitalized with COVID-19, Influenza,

Florina Cristiana Lucaciu1,2,3, Ovidiu Rosca2,3, Ana Maria Mihai1,2,3

  • 1Doctoral School, "Victor Babes" University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania.

Antibiotics (Basel, Switzerland)
|July 27, 2026
PubMed
Abstract

Insights

Antibiotic prescribing for COVID-19, influenza, and RSV often exceeds confirmed bacterial infections. Virus-specific stewardship and rapid diagnostics are crucial for appropriate antimicrobial use and combating resistance.

Area of Science:

  • Infectious Diseases
  • Public Health
  • Clinical Medicine

Background:

  • Hospitalized adults with COVID-19, influenza, or RSV frequently receive empirical antibiotics.
  • Limited synthesis exists on antibiotic prescribing, bacterial co-infection, antimicrobial resistance (AMR), and outcomes across these viral respiratory infections.

Purpose of the Study:

  • To systematically review and synthesize data on antibiotic use, bacterial co-infections, AMR, and outcomes in hospitalized adults with COVID-19, influenza A/B, or RSV.

Main Methods:

  • A PRISMA 2020 systematic review and meta-analysis of 39 studies involving 839,531 hospitalized adults.
  • Random-effects models were used to pool prevalence estimates, with sensitivity and publication-bias analyses.

Main Results:

  • Pooled antibiotic use was high: 62.56% for COVID-19, 57.48% for influenza A/B, and 76.03% for RSV, with significant heterogeneity.
  • Confirmed bacterial co-infection prevalence was lower (5.31% COVID-19, 18.66% influenza, 24.36% RSV), leading to high prescribing-to-infection ratios.
  • AMR data was limited to COVID-19, dominated by carbapenem-resistant Gram-negative organisms; bacterial complications correlated with ICU admission, longer hospitalization, and mortality.

Conclusions:

  • Antibiotic prescribing surpassed confirmed bacterial infections across all viral respiratory illnesses studied.
  • Findings necessitate cautious interpretation due to heterogeneity and diagnostic limitations; COVID-19 AMR data cannot be generalized to influenza or RSV.
  • Virus-specific antimicrobial stewardship should emphasize rapid diagnostics, systematic sampling, reassessment, and de-escalation when bacterial infection is ruled out.
Keywords:
SARS-CoV-2antimicrobial stewardshipempirical antibiotic prescribingmultidrug-resistant organismsprescribing-to-confirmation gaprespiratory syncytial virussecondary bacterial infectionviral respiratory infection

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