Researchers study bacterial co-infections and antibiotic use in COVID-19 patients

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In a recent study published in BMC Infectious Diseases, researchers estimated the frequency of bacterial co-infections among hospitalized coronavirus disease 2019 (COVID-19) patients and of antibiotic prescriptions in the initial COVID-19 period for appraising the usage of antibiotic stewardship criteria.

Study: Bacterial co-infection and antibiotic stewardship in patients with COVID-19: a systematic review and meta-analysis. Image Credit: CROCOTHERY/Shutterstock
Study: Bacterial co-infection and antibiotic stewardship in patients with COVID-19: a systematic review and meta-analysis. Image Credit: CROCOTHERY/Shutterstock

Studies have reported on the antibiotic overuse potential in the treatment of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection-associated pneumonia, with elevated antimicrobial resistance risks among patients. In light of the COVID-19 pandemic, the public health implications of antibiotic overuse could be massive. Clinical recommendations advocating the provision of the most appropriate therapy while maintaining responsible antibiotic use must be informed with research undertaken to understand the percentage of hospitalized patients with SARS-CoV-2 infection-associated pneumonia who acquire confirmed respiratory bacterial co-infections of acute duration, and associated pathogenic organisms.

About the study

In the present systematic review and meta-analysis, researchers estimated the frequency of confirmed bacterial co-infections among individuals hospitalized due to COVID-19-associated pneumonitis and empirical antibiotic use frequency among participants. They also identified criteria for stewardship in antibiotic use from the initial COVID-19 period to the present.

Data were searched on the LILACS, Pubmed, Web of Science, Cochrane Library, and Embase databases until 5 May 2021 for studies reporting the prevalence/proportion of bacterial co-infections among hospitalized COVID-19 patients and antibiotic use. Wherever available, data were obtained on the type and duration of antibiotic medications, adverse effects, and antibiotic stewardship policies. The team included records comprising individuals hospitalized with suspected LRTI (lower respiratory tract infection) and polymerase chain reaction (PCR)-confirmed COVID-19, published in German, English, French, Russian, Portuguese, or Spanish.

Only original records with ≥10 individuals, providing adequate data for appraising the method used were included. Studies included reported data on ≥1.0 of the outcomes: (i) the prevalence of bacterial co-infections among individuals hospitalized with confirmed COVID-19 patients; (ii) the prevalence of confirmed COVID-19 patients who were prescribed empirical antibiotics. The included records’ study designs comprised cohorts, case series, clinical trials, and registries.

The team excluded studies on antibiotic use for illnesses except for bacterial LRTIs, those comprising pregnant females and individuals with chronic immunosuppression, and studies documenting the rates of bacteria-caused co-infections with no mention of the clinical findings. Subgroup analysis was performed comprising critically ill COVID-19 patients requiring intensive care unit (ICU) admissions. The quality of included studies was based on the JBI (Joanna Briggs institute) critical appraisal tool.


In total, 6,798 records were obtained, of which, 4,132 records were subjected to initial screening, following which, the entire text of 162 studies was reviewed, from which 85 studies, comprising 31,123 COVID-19 patients, were considered for the final analysis. The overall prevalence/proportion of bacterial co-infections was 12.0%, and the prevalence rates of confirmed bacterial co-infections were 4.0% and 12.0% among all patients, and critically ill COVID-19 patients, respectively.

The estimated prevalence of bacterial co-infections in the subgroup analysis was 23.0%. The antibiotic usage rates among all patients and critically ill COVID-19 patients were 60.0% and 86.0%, respectively. The corresponding prevalence rates of empiric antibiotic usage were 62.0% and 66.0%, respectively. A few studies provided criteria for stopping antibiotic use.

Five studies mentioned the processes involved in antibiotic usage-related decision-making. A study reported that 52 out of 147 patients (35.0%) received empiric antibiotic therapy, of which 19 (37.0%) were administered antibiotic medications for >1.0 weeks in spite of negative cultures. The median duration of the empirical antibiotic course was 7.0 days. Another study mentioned that the antibiotics were recommended to be prescribed only for clinically suspected infections (beta-lactamase inhibitors/aminopenicillin of narrow-spectrum).

However, the clinicians decided on antibiotic prescriptions. The most frequently used antibiotic therapy in the period of observation were sulbactam/ampicillin (42.0%) and tazobactam/piperacillin (19.0%). Of interest, azithromycin medication had no mention in the recommendations, even though the antibiotic was prescribed to 43 COVID-19 patients (32%) in combination with other antibiotics.

A study reported on 84 individuals were prescribed empirical antibiotics for respiratory system-associated co-infections of bacterial etiology, and 93.0% of them were provided single antibiotic treatments. All antibiotics were administered intravenously initially and switched to the oral route among took 34 (41.0%) cases. The median periods of intravenous administration and oral administration were 5.0 days and 3.0 days, respectively.

An institutional study reported that 60.0% of patients were administered empirical antibiotics on the initial day of hospitalization, increasing to 72.0% within a week of hospitalization. Confirmed bacterial co-infections were documented for only one percent (n=12) of patients, and 84.0% of patients were prescribed antibiotics for 5.0 days. Switch from intravenous to oral route of antibiotic delivery was reported in 10% of cases.

A study reported that out of 965 patients receiving empirical antibiotics, 63.0% were prescribed antibiotics targeted at community-acquired pathogens, and the median period for antibiotic administration in inpatient settings was 3.0 days. The remaining studies stated that local-level guidelines for empirical antibiotic therapy among COVID-19 pneumonitis patients must be followed.

Overall, the study findings showed that there is currently inadequate evidence to support extensive antibiotic use among most hospitalized COVID-19 pneumonitis patients since the prevalence of bacterial co-infections was low. Guidelines to promote more tailored antibiotic administrations among hospitalized COVID-19 patients are needed.  

Journal reference:
Pooja Toshniwal Paharia

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Pooja Toshniwal Paharia

Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.


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