Epidemiologist Dr. Sara Cosgrove typically spends her days working on antibiotic stewardship at Johns Hopkins Hospital in Baltimore, monitoring the use of antibiotics to ensure they are being appropriately administered. But when response to the novel coronavirus ramped up in mid-March, she was pulled into COVID-19 relief efforts exclusively due to her expertise in infectious disease.
“I did no antibiotic stewardship in March, April or May, and I did all hospital epidemiology in March, April and May,” said Cosgrove, past president of the Society for Healthcare Epidemiology in America and director of antimicrobial stewardship at Johns Hopkins Hospital.
During those three months, Cosgrove said use of antibiotics targeted for pneumonia treatment spiked in the hospital setting, largely because COVID-19 patients were overwhelmingly being prescribed these drugs unnecessarily. Johns Hopkins’ experience matches trends nationally, driving concerns among infectious disease experts that antibiotic resistance will continue to worsen as a second wave of COVID-19 cases collides with flu season. The World Health Organization ranked antibiotic resistance as one of its top 10 global public health threats. In the U.S. alone, about 2.8 million drug-resistant infections occur each year, resulting in more than 35,000 deaths. Similar numbers have been reported in the European Union.
Although inroads have been made in combating antibiotic resistance, infection control specialists are worried that misuse of antibiotics on COVID-19 patients—on top of cuts to stewardship programs and burnout of infection control staff—will only worsen the crisis.
“As people prepare for a second wave and there are concerns that healthcare systems may get a lot of critically ill patients, that is going to strain the systems, and antibiotic stewardship programs are already strained, so it really is kind of scary,” said Dr. Michael Stevens, director of the antimicrobial stewardship program at VCU Health in Richmond, Va.
Research thus far shows that patients who test positive for COVID-19 are likely to get an antibiotic although most don’t have a bacterial infection. One study, published last month in the journal of Clinical Infectious Diseases, found nearly 57% of 1,705 patients treated for COVID-19 in 38 Michigan hospitals from March to June received an antibacterial therapy, but only 3.5% had a confirmed bacterial infection.
There are a few reasons why inappropriate prescribing is occurring. At the onset of the pandemic, little was known about the novel coronavirus and effective treatments.
“When doctors don’t have a lot of medications to treat COVID and yet they can give antibiotics, it makes them feel like they are doing something,” said Steffanie Strathdee, an epidemiology researcher and associate dean of global health and sciences at the University of California at San Diego School of Medicine.
It also wasn’t clear in early spring how common bacterial co-infections were for COVID-19 patients and testing for the virus wasn’t very robust. That meant providers couldn’t quickly rule out bacterial infections.
“A lot of antibiotic use is driven by uncertainty,” Stevens said. “Could there be a bacterial superinfection? If it’s possible, providers are going to want to treat it, especially if (the patient is) still under investigation for COVID-19.”
At the same time, front-line clinicians who aren’t specialists in critical care have been asked to step in and help. Those caregivers aren’t as familiar with respiratory tract infections and protocols in place for antibiotic use, Cosgrove said.
Joint Commission surveys of hospitals for accreditation, which involve reviewing antibiotic stewardship programs, have dropped during the pandemic. Dr. Tim Sorg, an infectious disease physician and surveyor, said he’s concerned that staff have been taken away from stewardship to help with COVID-19 response. “Those folks are probably being pulled in different directions because of this crisis, so there is probably lesser focus on antimicrobial stewardship,” he said.
Johns Hopkins found COVID-19 units staffed with hospitalists had a higher level of antibiotic prescribing compared with COVID-19 units staffed with infectious disease specialists.
Although there are reasons to be concerned about antibiotic resistance during COVID-19, Greg Frank, director of the coalition Working to Fight AMR, said there is some evidence from the federal government that the decline in surgeries and other routine services helped offset the high use of antibiotics on COVID patients because the drugs weren’t being used for other conditions.
Institutions with robust COVID-19 testing and strong antibiotic stewardship programs have likely been able to make progress on inappropriate prescribing since March, Stevens said.
VCU Health experienced an uptick of antibiotic use for pneumonia during the initial weeks of the pandemic, but by May it decreased. The shift coincided with a policy in late April requiring universal COVID-19 screening at the time of admission, Stevens said. VCU also maintained antibiotic stewardship practices including consulting with patients and enforcing antibiotic treatment guidelines.
Since Cosgrove and her team returned to antimicrobial stewardship duties, an evaluation has been done on every COVID-19 patient admitted during the initial months of the pandemic. They found that the bacterial co-infection rate hovered around 1% to 3%. That information has been helpful to front-line caregivers because they know a COVID-19 patient is unlikely to need antibiotics, Cosgrove said.
“Just being able to get that information and create a feedback loop, which is regular stewardship, has been helpful,” she said.
Considering the impact stewardship staff has had response to COVID-19, she cautioned against eyeing cuts to those units for cost savings, saying, “We are pretty good to have around.”