Skip to main content Accessibility help
×
Home
Hostname: page-component-7f7b94f6bd-8mfwn Total loading time: 0.334 Render date: 2022-06-28T19:46:13.912Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Impact of COVID-19 on pneumonia-focused antibiotic use at an academic medical center

Published online by Cambridge University Press:  23 July 2020

Matthew J. Nestler
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia
Emily Godbout
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia Healthcare Infection Prevention Program. Virginia Commonwealth University Health System, Richmond, Virginia
Kimberly Lee
Affiliation:
Virginia Commonwealth University Health System, Richmond, Virginia
Jihye Kim
Affiliation:
Virginia Commonwealth University Health System, Richmond, Virginia
Andrew J. Noda
Affiliation:
Virginia Commonwealth University Health System, Richmond, Virginia
Perry Taylor
Affiliation:
Virginia Commonwealth University Health System, Richmond, Virginia
Rachel Pryor
Affiliation:
Healthcare Infection Prevention Program. Virginia Commonwealth University Health System, Richmond, Virginia
J. Daniel Markley
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
Michelle Doll
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia Healthcare Infection Prevention Program. Virginia Commonwealth University Health System, Richmond, Virginia
Gonzalo Bearman
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia Healthcare Infection Prevention Program. Virginia Commonwealth University Health System, Richmond, Virginia
Michael P. Stevens*
Affiliation:
Virginia Commonwealth University School of Medicine, Richmond, Virginia Healthcare Infection Prevention Program. Virginia Commonwealth University Health System, Richmond, Virginia
*
Author for correspondence: Michael P. Stevens, E-mail: michael.stevens@vcuhealth.org
Rights & Permissions[Opens in a new window]

Abstract

Type
Letter to the Editor
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved

To the Editor—Optimizing antimicrobial use and stewardship during the global spread of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) is an important goal for health systems. A review published in May 2020 found that only 8% of patients with coronavirus disease 2019 (COVID-19) had a bacterial or fungal coinfection, while 72% of patients received antimicrobial therapy.Reference Rawson, Moore and Zhu1 Many patients requiring hospitalization for COVID-19 present with symptoms mimicking community-acquired bacterial pneumonia prompting empiric antibiotic use.Reference Huttner, Catho, Pano-Pardo, Pulcini and Schouten2 High antibiotic use might also stem from provider experience with hospitalized influenza patients of which 11%–35% may have a bacterial superinfection.Reference Huttner, Catho, Pano-Pardo, Pulcini and Schouten2,Reference Klein, Monteforte, Gupta, Jiang, May and Hsieh3 Antibiotic usage trends are starting to be published; a study by Velasco Arnaiz et alReference Velasco Arnaiz, López Ramos and Simó Nebot4 showed increased pediatric inpatient azithromycin and ceftriaxone use in March and April of 2020 compared to the same months in 2019.

We examined inpatient pneumonia-focused antibiotic use trends at Virginia Commonwealth University (VCU) Health System, an 865-bed urban academic medical center. We hypothesized that antibiotic days of therapy per 1,000 patient days (DOT per 1,000 PD) for key antimicrobials targeting pneumonia would be affected for April and May of 2020 when compared to the average DOT per 1,000 PD over the preceding year due to the impact of COVID-19 on our health system.

Methods

The antibiotics ceftriaxone, azithromycin, levofloxacin, doxycycline, cefepime, piperacillin-tazobactam, meropenem, and vancomycin were chosen due to their common use for either community-acquired pneumonia (CAP) or hospital-acquired/ventilator-associated pneumonia (HAP/VAP) coverage. Antibiotic DOT per 1,000 PDs were examined for 3 units: a medical intensive care unit (MICU), a coronary intensive care unit (CICU), and a progressive medicine unit. The percentages of COVID-19–positive patient days were calculated for each unit by month. For each unit, the normality of the April 2019–March 2020 monthly data were confirmed using a histogram and kurtosis or skewness scores. Seasonality was also checked via graph and determined to not be a substantial influence on the data. A 2-sample t test assuming equal variances was performed with the first group being the April 2019–March 2020 monthly data and the second being April or May 2020. Thus, we tested the null hypothesis that antibiotic use in April or May 2020 was the same as the mean use from April 2019 to March 2020. The 2-tailed P values are reported in Table 1 and P ≤ .05 was considered significant. The analyses were conducted using Excel version 2002 software (Microsoft, Redmond, WA).

Table 1. Antibiotic Use for April and May 2020 Versus April 2019–March 2020

Note. MICU, medical intensive care unit; CICU, cardiac intensive care unit; PM, progressive medicine unit; Pip-Tazo, piperacillin-tazobactam; PD, patient days; DOT, days of therapy.

Results

We detected a significant increase in April 2020 ceftriaxone use in the MICU (P < .001), the CICU (P ≤ .001), and the progressive medicine unit (P = .0024) as well as April 2020 azithromycin use in the MICU (P = .031) and PM (P < .001). There was a significant decrease for May 2020 levofloxacin use in the MICU (P = .0066) and the progressive medicine unit (P = .029) (Table 1).

Discussion

All 3 units demonstrated a significant increase in ceftriaxone use in April 2020. The MICU and the progressive medicine unit also demonstrated increased azithromycin use in April 2020. Notably, azithromycin use did not significantly increase in the CICU (perhaps related to a greater concern for risk for cardiac toxicity from this drug). Ceftriaxone and azithromycin are commonly used for community-acquired pneumonia, and we suspect that their use increased to empirically cover bacterial superinfection in patients who were suspected of having COVID-19. Interestingly, the April and May use patterns appeared to be independent of unit COVID-19 patient days (Table 1). Our hospital began testing all patients for SARS-CoV-2 on admission to the hospital on April 27, which may explain the reversion to baseline usage from April to May, especially in the CICU, where the total percentage of COVID-19–positive patients remained low. Our MICU is a closed unit with a limited number of attending providers, and patients with COVID-19 in the progressive medicine unit were mostly cared for by our hospital medicine group. Possibly, these 2 respective groups developed experience with managing these patients over the course of April and this impacted the reversion in antibiotic use trends. More research is needed to more fully understand these use trends.

There was no significant increase in the use of antipseudomonal β-lactams (ie, cefepime, piperacillin-tazobactam, and meropenem) or vancomycin across the units studied. This finding suggests that clinicians were empirically using CAP-focused antibiotics in April 2020 (with the exception of the CICU with azithromycin) as opposed to empirically giving HAP- or VAP-focused antibiotics. Our hospital has a longstanding and aggressive antimicrobial stewardship program that has published CAP and HAP/VAP guidelines. We suspect that these guidelines helped limit the use of HAP/VAP-focused antibiotic coverage in April; HAP is defined in our guidelines as occurring ≥48 hours after admission with pneumonia not present at the time of admission. Additionally, meropenem is restricted at VCU Health. The decrease in levofloxacin use in the MICU and PM units during May 2020 is not well understood and warrants further study.

This analysis has several limitations. Because it was conducted at a single medical center, our results may not be generalizable. Additionally, our vancomycin use data include both IV and oral formulations, although we think the impact of this factor on our data is very low because IV administration is predominant at our hospital.

The COVID-19 pandemic has dramatically impacted health systems, and concern that antibiotic use may drive antibiotic resistance is widespread. Our results indicate an initial uptick in CAP-focused empiric antibiotic use with a subsequent reversion to baseline use. Notably, we did not see a significant increase in the use of antipseudomonal β-lactam antibiotics or vancomycin. The roles of active antimicrobial stewardship, local treatment protocols, and universal COVID-19 testing on antibiotic use all warrant further study.

Acknowledgments

Financial support

No financial support was provided relevant to this article.

Conflicts of interest

All authors report no conflicts of interest relevant to this article.

References

Rawson, TM, Moore, LSP, Zhu, N, et al. Bacterial and fungal co-infection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis 2020. doi: 10.1093/cid/ciaa530.CrossRefGoogle Scholar
Huttner, BD, Catho, G, Pano-Pardo, JR, Pulcini, C, Schouten, J. COVID-19: don’t neglect antimicrobial stewardship principles! Clin Microbiol Infect. 2020 April 30 [Epub ahead of print]. doi: 10.1016/j.cmi.2020.04.024 CrossRefGoogle Scholar
Klein, EY, Monteforte, B, Gupta, A, Jiang, W, May, L, Hsieh, YH, et al. The frequency of influenza and bacterial coinfection: a systematic review and meta-analysis. Influenza Other Respir Virus 2016;10:394e403.CrossRefGoogle Scholar
Velasco Arnaiz, E, López Ramos, MG, Simó Nebot, S, et al. Pediatric antimicrobial stewardship in the COVID-19 outbreak Infect Control Hosp Epidemiol 2020 June 24 [Epub ahead of print]. doi: 10.1017/ice.2020.312 CrossRefGoogle Scholar
Figure 0

Table 1. Antibiotic Use for April and May 2020 Versus April 2019–March 2020

You have Access Open access
15
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Impact of COVID-19 on pneumonia-focused antibiotic use at an academic medical center
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Impact of COVID-19 on pneumonia-focused antibiotic use at an academic medical center
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Impact of COVID-19 on pneumonia-focused antibiotic use at an academic medical center
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *