Experts lay out antibiotic stewardship lessons from COVID-19

A panel of consultants with the Society for Healthcare Epidemiology of America (SHEA) printed an announcement final week on methods to enhance antibiotic use and stewardship throughout infectious illness pandemics and outbreaks.

The statement, printed in An infection Management & Hospital Epidemiology, addresses widespread inappropriate antibiotic use through the COVID-19 pandemic. The peak of pointless antibiotic use passed off within the early phases of the pandemic, when hospitals have been flooded with severely in poor health sufferers, diagnostic exams have been unavailable or took a number of days to return outcomes, no remedies have been out there, and healthcare suppliers wished to do one thing to assist.

The state of affairs has improved since then, with extra dependable exams, faster turnaround occasions, and established remedies decreasing use of antibiotics in COVID-19 sufferers. In instances by which empiric antibiotics are prescribed due to considerations about bacterial coinfections, they’re discontinued shortly.

Antibiotic initiation, nonetheless, has remained excessive, and there are considerations that antibiotic overprescribing in COVID-19 sufferers is likely one of the elements contributing to an increase in multidrug-resistant hospital infections.

However the assertion is much less a criticism of how antibiotics have been misused through the pandemic than an acknowledgement of the challenges posed by COVID-19 and suppliers’ problem not utilizing antibiotics in an setting of heightened sickness and uncertainty. It is also an try to determine evidence-based pointers for a way the healthcare system and antibiotic stewardship applications (ASPs) ought to react through the subsequent public well being emergency brought on by a viral respiratory illness, says the lead creator.

“The purpose we have been attempting to make is that there are evidence-based rules which you could observe…and we expect these rules may be utilized to the subsequent respiratory viral epidemic,” Tamar Barlam, MD, director of Antimicrobial Stewardship at Boston Medical Middle and chair of the SHEA Antimicrobial Stewardship Committee, informed CIDRAP Information.

‘Low threshold’ for antibiotic use

The excessive degree of antibiotic use seen within the early months of the pandemic is definitely comprehensible, Barlam says. Hospitals have been overwhelmed with severely in poor health sufferers sickened by a mysterious new respiratory sickness, and little may very well be completed for them. Clinicians desperately wanted to do something for these sufferers, lots of whom introduced as having bacterial pneumonia. There have been additionally early media-fueled stories that the antibiotic azithromycin could be efficient.

All these elements led to a “low threshold” for antibiotic initiation, Barlam and her colleagues write.

“If we are able to bear in mind again to that time, there have been no vaccines, there have been no remedies. It wasn’t clear if there was any position for any variety of brokers,” she mentioned. “And in some ways, giving an antibiotic is simply simpler than having to actually suppose it by way of.”

However even when testing turned extra dependable and sufferers have been coming in with basic indicators of COVID-19, prescribing antibiotics turned an virtually “knee jerk” response, with some sufferers receiving broad-spectrum medicine extra acceptable for hospital-associated infections.

“To deal with somebody who was principally wholesome till they bought COVID as if they’d a hospital-associated pneumonia…wasn’t acceptable,” Barlam mentioned. “However we have been seeing it on a regular basis.”

One other issue early within the pandemic, and one which has continued to drive antibiotic use in COVID-19 sufferers, is concern about bacterial coinfections, particularly in older sufferers with different morbidities. However Barlam and her colleagues notice that research have proven that solely 3.1% to five.5% of COVID-19 sufferers have bacterial coinfections.

To stop the sort of antibiotic use in future viral respiratory outbreaks, the SHEA assertion recommends first that healthcare suppliers restrict initiation of antibiotics when there’s a “excessive pre-test likelihood” for a viral an infection, even in instances by which correct diagnostics aren’t available.

“There is no such thing as a proof that routine antibiotics are wanted for respiratory viral pandemics in sufferers who don’t exhibit clear indicators of bacterial coinfection,” the assertion says.

The assertion goes on to say that healthcare suppliers can carry out inflammatory marker exams, such C-reactive protein or procalcitonin exams, however that these markers shouldn’t be used as the premise for initiation of antibiotics as a result of they will not be indicative of a bacterial or fungal an infection.

Barlam and her colleagues acknowledge that it is vital for suppliers to establish sufferers who might require antibiotic initiation—comparable to those that have signs indicating bacterial pneumonia or one other bacterial coinfection—and to observe with microbiologic testing to substantiate the an infection and alter antibiotic remedy accordingly. However they warn towards overuse of diagnostic exams when there aren’t any indicators of bacterial coinfection.

The position of stewardship

Lastly, the SHEA assertion emphasizes the vital position that ASPs can play in future outbreaks or pandemics, not simply by way of growing therapy pointers and monitoring acceptable antibiotic use. ASPs also can present recommendation and help for clinicians within the face of medical uncertainty and, as they’ve completed through the COVID-19 pandemic, assist consider and implement different therapy regimens.

“Stewardship is definitely a part of an emergency response,” Barlam mentioned.

Barlam is aware of that every time a viral outbreak or pandemic happens, the challenges seen throughout COVID will possible rear their head once more. However she hopes that the assertion clearly lays out the evidence-based steps that suppliers ought to take to attenuate pointless antibiotic use in that occasion.

“I believe we all know that if there’s one other large outbreak, that we’re going to have to bolster and reeducate and supply steerage,” she mentioned. “Nevertheless it’s at all times good to put it out in a method that you’ve a standard lexicon which you could work from.”

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