Why does bacterial resistance occur when antibiotics are used to treat COVID-19?

Why Bacterial Resistance Occurs When Antibiotics Are Used in COVID-19

Bacterial resistance occurs with inappropriate antibiotic use in COVID-19 patients because the prevalence of bacterial co-infection is low (only 5.1% initially and 13.1% secondary), yet antibiotics are prescribed in over 70% of cases, creating selective pressure for resistant organisms without clinical justification. 1

Prevalence of Bacterial Infections in COVID-19

• Bacterial co-infection upon initial presentation is rare in COVID-19 patients, with only 5.1% having bacterial co-infection at admission 1
• Secondary bacterial infections during hospitalization occur in approximately 13.1% of COVID-19 patients 1
• The overall incidence of respiratory tract infections and/or bloodstream infections in COVID-19 patients is only 8.8% 1
• COVID-19 has a significantly lower rate of bacterial co-infection compared to influenza, where co-infection rates range from 11-35% 1

Inappropriate Antibiotic Use in COVID-19

• Despite low bacterial infection rates, antibiotics are prescribed in over 70% of COVID-19 patients 1
• This widespread use of antibiotics without clinical justification creates selective pressure for resistant organisms 1, 2
• Indiscriminate use of antibiotics during the COVID-19 pandemic has led to concerns about increasing antimicrobial resistance 3, 4
• The gratuitous use of antibiotics for COVID-19 treatment raises concerns about the emergence of antimicrobial resistance (AMR) 2

Mechanism of Resistance Development

• Unnecessary antibiotic exposure allows naturally resistant bacteria to survive and multiply while susceptible bacteria are eliminated 1, 4
• Prolonged hospitalization and respiratory support in COVID-19 patients increases the risk of acquiring resistant infections when antibiotics are used unnecessarily 1
• Overuse of antibiotics may cause unnecessary adverse events, lengthen hospital stays, increase medical expenditure, and impact antimicrobial resistance 1
• Multidrug-resistant pathogens are a significant concern in the COVID-19 era, particularly in patients requiring mechanical ventilation 1

Guidelines for Appropriate Antibiotic Use

• Strong recommendation against routine prescription of antibiotics in COVID-19 patients 1
• Antibiotics should only be prescribed based on clinical justifications such as disease manifestations, severity, imaging findings, and laboratory data 1, 3
• A comprehensive microbiologic workup should be performed before administering empirical antibiotics 1
• If antibiotics are started, they should be discontinued within 48 hours if cultures and urinary antigen tests show no signs of bacterial pathogens 1, 3

Risk Factors for Bacterial Infections in COVID-19

• Critically ill COVID-19 patients, especially those requiring ICU admission or mechanical ventilation, have a higher risk of bacterial infections 1
• Mechanical ventilation increases the risk of bacterial infections (aOR 1.41) 1
• Higher white blood cell counts, higher C-reactive protein levels, or procalcitonin >0.5 ng/mL may indicate a higher possibility of bacterial co-infection 1, 3
• However, serum biomarkers alone should not be used to decide when to start antibiotics, especially in non-critically ill patients 1

Consequences of Antibiotic Misuse

• Unnecessary antibiotic use increases the risk of subsequent hospital-acquired pneumonia caused by resistant bacteria 1
• Bacterial co-infections and secondary infections are associated with significant increases in mortality and longer hospital stays 1
• The wrong consumption of antibiotics during the COVID-19 pandemic has disastrous effects on antimicrobial resistance management and antibiotic stewardship programs 4
• COVID-19 patients in regions with high antimicrobial resistance may be fighting on two fronts: the virus and multidrug-resistant bacteria 4

Recommendations for Antibiotic Stewardship

• Prescribing antibiotics in COVID-19 patients should adhere to the principles of antimicrobial stewardship 1
• Comprehensive evaluation for bacterial co-infection, including clinical symptoms, microbiology evidence, and inflammatory biomarkers, is crucial 1
• Antibiotics should be de-escalated or discontinued based on identified pathogens and susceptibility testing results 1
• Current control policies to manage antimicrobial resistance and prioritization of antibiotic stewardship plans are mandatory during this pandemic 4