ANTIBIOTICS OVERUSE/ MISUSE IN COVID-19 AND HOW TO MITIGATE?

Abstract

 Antibacterial drugs, also referred to as antibiotics, prevent the growth and development of bacteria. They are used to treat illnesses caused by pathogenic bac­teria and include a variety of potent medications. For viral infections including common cold and flu, anti­biotics are not recommended. Corona Virus Disease (COVID-19) is also an infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and antibiotics are mostly not required for its management. However, it is possible that secondary bacterial infec­tions occur in some patients with COVID-19 leading to increased disease severity and possibly adverse out­come, for which antibiotics are recommended. These superimposed bacterial infections in COVID-19 are re­portedly more common (14% to 28%) in hospitalised patients with severe disease and in intensive care unit (ICU) settings.1,2

Antibiotics are not indicated in most cases of COVID-19 but too many of these patients get unneed­ed antibiotics on an empirical basis. Most, if not all, of the patients hospitalized with suspected or confirmed COVID-19 in major hospitals of Khyber Pakhtunkhwa, Pakistan have received antibiotics. In fact, the majority of these patients were on double and sometimes triple antibiotics combination. Besides Azithromycin other broad-spectrum antibiotics like Meropenem, Sulbac­tum-Cefoperazone and Tazobactam-Piperacillin have been commonly prescribed in our hospitals. Azithromy­cin in combination with Hydroxychloroquine was initial­ly thought to be having some antiviral effect against SARS-CoV-2 and was used by our COVID-19 patients either themselves or on doctor’s advice. Its efficacy, however, against COVID-19 was never established, and opposing conclusions were drawn in different stud­ies.3,4 Furthermore the investigators of the RECOVERY trial found no additional benefit of Azithromycin when added to the standard care regimen.5

This overuse of antibiotics in COVID-19 is not limited to our setup. Data suggest that 50-75% of COVID-19 patients received antibiotics at some stage in developed countries as well. In Michigan state of United States, over half of the hospitalized patients with COVID-19 during the peak months received antibiotics. Only 3.5% of the patients in their cohort had a super­vening bacterial infection. This amounts to putting 20 extra patients on antibiotics unnecessarily in the hope of treating one patient having both bacterial and viral infections.6

In general, Antibiotics put patients at the risk of opportunistic infections like Clostridium Difficile which can worsen their chances of recovery. It also expos­es the users to many other adverse effects associated with their use. Besides, it adds to the ongoing pandem­ic of antibiotic resistance and the development of su­perbugs.7 Antibiotics resistance develops when these drugs are inappropriately prescribed and the bacteria develop a mechanism to evade these drugs. Health­care facilities are the main source of the emergence of antibiotic resistance. Furthermore, by inappropriate­ly using Azithromycin in COVID-19 patients, it might lose its efficacy again XDR Salmonella which is rapidly spreading across Pakistan.8

At times it is difficult to differentiate between vi­ral and bacterial pneumonia but when RT-PCR for COVID-19 result is positive one should start thinking about stopping the antibiotics unless there is a super­vening bacterial infection. It is recommended that pa­tients should not be put on antibiotics for mild COVID-19. In moderate to severe disease, antibiotics should only be prescribed when there is evidence of superimposed bacterial infection as shown by raised White cell count, positive reports of culture, or raised Procalcitonin level. Remember low Procalcitonin is a sensitive marker of ruling out concomitant bacterial infection. In ICU admit­ted patients, PCT levels of more than 1.00 microgram/L rule in, whereas concentrations of less than 0.25 microgramg/L rule out secondary bac­terial infections with good predictive values.9 CRP is an acute-phase reactant that rises in moderate to severe cases but more so in bacterial superinfection and may help in deciding the use of antibiotics in the later stage of COVID-19.10 By all means, the duration of antibiotic treatment should not exceed 7 days in general and evidence suggests that shorter durations can reduce the adverse ef­fects of antimicrobials.11

In summary, antibiotics should not be prescribed to prevent or treat COVID-19. However, if a patient is hospitalised with COVID-19, he/ she may need antibiotics as bacterial co-infection/superinfection is pos­sible. The latter may be diagnosed in the appropriate clinical context and after doing relevant investigations.