Original Research

Pharmacist-Led Antimicrobial Stewardship and Antibiotic Use in Hospitalized Patients With COVID-19

Fed Pract. 2023 June;40(6):178-181 | doi:10.12788/fp.0380

Author(s):

Ashfaq Shafiq, PharmD, BCPS, BCCCP, BCIDP

Background: During the COVID-19 pandemic, a significant increase in the use of empiric antibiotic therapy has been observed especially in patients hospitalized with COVID-19. Improving antibiotic prescribing is one of the main goals of the antimicrobial stewardship program (ASP). The ASP pharmacists have a scope of practice that authorizes changes in anti-infective therapy.

Methods: We aimed to describe antibiotic prescribing in patients hospitalized with COVID-19 at Veterans Affairs Southern Nevada Healthcare System with a pharmacist-led ASP and to determine the prevalence of bacterial coinfection in this patient population. We performed a retrospective chart review of patients admitted to the facility from November 1, 2020, to January 31, 2021.

Results: A total of 199 patients were admitted to the hospital for laboratory-confirmed COVID-19 infection during the study period and 61 patients (31%) received ≥ 1 antibiotic on hospital admission and 138 (69%) did not receive antibiotics. Forty-seven patients (77%) had antibiotics discontinued by the ASP team within 72 hours of admission. Of the 199 admitted, 6 (3%) had microbiologically confirmed bacterial coinfection. Pseudomonas aeruginosa was the most common organism (3 sputum cultures) followed by Klebsiella oxytoca (2 sputum cultures). Sixteen patients (8%) developed a nosocomial infection during their hospital stay.

Conclusions: Up to 31% of patients hospitalized for COVID-19 infection received empiric antibiotic treatment for concern of bacterial coinfection. Pharmacist-led ASP led to early discontinuation of antibiotics in many patients. A thorough clinical workup to determine the risk of bacterial coinfection in patients with COVID-19 is important before starting empiric antibiotic therapy. It is essential to continue promoting the ASP during the COVID-19 pandemic to ensure responsible antibiotic use and prevent antimicrobial resistance.

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References

1. Demirjian A, Sanchez GV, Finkelstein JA, et al. CDC grand rounds: getting smart about antibiotics. MMWR Morb Mortal Wkly Rep. 2015;64(32):871-873. doi:10.15585/mmwr.mm6432a3

2. Nearly half a million Americans suffered from Clostridium difficile infections in a single year. Centers for Disease Control and Prevention. Updated March 22, 2017. Accessed March 21, 2023. https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html

3. Centers for Disease Control and Prevention. About antimicrobial resistance. Updated October 5, 2022. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/about.html

4. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf

5. Centers for Disease Control and Prevention. COVID-19 & antibiotic resistance. Updated February 25, 2022. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/covid19.html

6. Russell CD, Fairfield CJ, Drake TM, et al. Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. Lancet Microbe. 2021;2(8):e354-e365. doi:10.1016/S2666-5247(21)00090-2

7. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020;26(12):1622-1629. doi:10.1016/j.cmi.2020.07.016

8. Coenen S, de la Court JR, Buis DTP, et al. Low frequency of community-acquired bacterial co-infection in patients hospitalized for COVID-19 based on clinical, radiological and microbiological criteria: a retrospective cohort study. Antimicrob Resist Infect Control. 2021;10(1):155. doi:10.1186/s13756-021-01024-4

9. Centers for Disease Control and Prevention. The core elements of hospital antibiotic stewardship programs: 2019. Accessed March 21, 2023. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf

10. Relph KA, Russell CD, Fairfield CJ, et al; International Severe Acute Respiratory and Emerging Infections Consortium; Coronavirus Clinical Characterisation Consortium (ISARIC4C) Investigators. Procalcitonin is not a reliable biomarker of bacterial coinfection in people with Coronavirus Disease 2019 undergoing microbiological investigation at the time of hospital admission. Open Forum Infect Dis. 2022;9(5):ofac179. doi:10.1093/ofid/ofac179

The inappropriate use of antibiotics is associated with an increased risk of antibiotic resistance, health care costs, and risk of adverse drug reactions.¹ According to the Centers for Disease Control and Prevention (CDC), a 10% decrease in overall antibiotic use across different wards was associated with a 34% decrease in Clostridioides difficile (C difficile) infections.² In addition, antimicrobial resistance accounts for > 2.8 million infections and > 35,000 deaths each year.³ The estimated total economic costs of antibiotic resistance to the US economy have ranged as high as $20 billion in excess direct health care costs.⁴ A main goal of an antimicrobial stewardship program (ASP) is to optimize antibiotic use to prevent the adverse consequences of inappropriate antibiotic prescribing.

During the COVID-19 pandemic, increased use of empiric antibiotic therapy has been observed. According to the CDC, almost 80% of patients hospitalized with COVID-19 received an antibiotic from March 2020 to October 2020.⁵ Studies were conducted to investigate the prevalence of bacterial coinfection in patients with COVID-19 and whether antibiotics were indicated in this patient population. A United Kingdom multicenter, prospective cohort study showed a high proportion of patients hospitalized with COVID-19 received antimicrobials despite microbiologically confirmed bacterial infections being rare and more likely to be secondary infections.⁶

Many other studies have reported similar findings. Langord and colleagues found the prevalence of bacterial coinfection in patients with COVID-19 was 3.5% but that 71.9% received antibiotics.⁷ Coenen and colleagues identified 12.4% of the patients with possible and 1.1% of patients with probable bacterial coinfection, while 81% of the study population and 78% of patients were classified as unlikely bacterial coinfection received antibiotics.⁸

At Veterans Affairs Southern Nevada Healthcare System (VASNHS), an ASP team consisting of an infectious disease (ID) physician and 2 pharmacists provide daily prospective audits with intervention and feedback along with other interventions, such as providing restricted order menus, institutional treatment guidelines, and staff education to help improve antibiotic prescribing. The ASP pharmacists have a scope of practice to make changes to anti-infective therapies. The purpose of this study was to describe antibiotic prescribing in patients hospitalized with COVID-19 from November 1, 2020, to January 31, 2021, in an ASP setting led by pharmacists.

References

1. Demirjian A, Sanchez GV, Finkelstein JA, et al. CDC grand rounds: getting smart about antibiotics. MMWR Morb Mortal Wkly Rep. 2015;64(32):871-873. doi:10.15585/mmwr.mm6432a3

2. Nearly half a million Americans suffered from Clostridium difficile infections in a single year. Centers for Disease Control and Prevention. Updated March 22, 2017. Accessed March 21, 2023. https://www.cdc.gov/media/releases/2015/p0225-clostridium-difficile.html

3. Centers for Disease Control and Prevention. About antimicrobial resistance. Updated October 5, 2022. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/about.html

4. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf

5. Centers for Disease Control and Prevention. COVID-19 & antibiotic resistance. Updated February 25, 2022. Accessed March 21, 2023. https://www.cdc.gov/drugresistance/covid19.html

6. Russell CD, Fairfield CJ, Drake TM, et al. Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. Lancet Microbe. 2021;2(8):e354-e365. doi:10.1016/S2666-5247(21)00090-2

7. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020;26(12):1622-1629. doi:10.1016/j.cmi.2020.07.016

8. Coenen S, de la Court JR, Buis DTP, et al. Low frequency of community-acquired bacterial co-infection in patients hospitalized for COVID-19 based on clinical, radiological and microbiological criteria: a retrospective cohort study. Antimicrob Resist Infect Control. 2021;10(1):155. doi:10.1186/s13756-021-01024-4

9. Centers for Disease Control and Prevention. The core elements of hospital antibiotic stewardship programs: 2019. Accessed March 21, 2023. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf

10. Relph KA, Russell CD, Fairfield CJ, et al; International Severe Acute Respiratory and Emerging Infections Consortium; Coronavirus Clinical Characterisation Consortium (ISARIC4C) Investigators. Procalcitonin is not a reliable biomarker of bacterial coinfection in people with Coronavirus Disease 2019 undergoing microbiological investigation at the time of hospital admission. Open Forum Infect Dis. 2022;9(5):ofac179. doi:10.1093/ofid/ofac179

Pharmacist-Led Antimicrobial Stewardship and Antibiotic Use in Hospitalized Patients With COVID-19

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