Overuse of antibiotics, delivery of tests and procedures that have little or no clinical benefit is a huge problem in health care, and one that has gained much more attention over the past decade. But despite efforts to reduce overuse like Choosing Wisely, rates of low-value care have barely budged.

1. Antibacterial therapy in COVID-19
patients - an evidence based guideline
Dr Jay Prakash
Assistant Professor (Dept. of Critical Care Medicine)
RIMS, Ranchi

2. • Coronavirus disease 2019 (COVID-19) pandemic due to the
novel SARS Coronavirus (SARS-CoV-2) can lead to a wide
spectrum of disease, ranging from very mild symptoms of
upper respiratory tract infection to life-threatening
pneumonia.
• During hospitalization it may be difficult to distinguish
between severe COVID-19 and bacterial secondary infections.

3. • In several reports the majority of hospitalized patients with
COVID-19 were treated with broad-spectrum antibiotics with
unknown efficacy .
• In 2017 a joined guideline on the management of hospitalized
patients with CAP was issued .
(Wiersinga WJ, Bonten MJ, Boersma WG, Jonkers RE, Aleva RM, Kullberg BJ, et al. Management of
community-acquired pneumonia in adults: 2016 guideline update from the Dutch working party on
antibiotic policy (SWAB) and Dutch association of chest Physicians (NVALT). Netherlands J Med
2018;76:4e13)

5. • Overuse of antibiotics, delivery of tests and procedures that have
little or no clinical benefit is a huge problem in health care, and
one that has gained much more attention over the past decade.
But despite efforts to reduce overuse like Choosing Wisely, rates
of low-value care have barely budged.
(Judith Garber | March 29, 2021) https://lowninstitute.org/to-stop-overuse-we-have-to-
focus-on-and-measure-the-harms/#.YG3byMv7J9Q.link

6. Objectives
• Evaluate the available data on the rate of bacterial co-infection
and secondary infection in patients presenting with COVID-19.
• Discuss antibiotic overuse in patients with COVID-19.
• Identify practices to complement Antimicrobial Stewardship
Programme during the COVID-19 pandemic

7. • Widespread and excessive antibiotic use is possible. Why?
– Anxiety, uncertainty surrounding a global pandemic
– Absence of antiviral treatment with proven efficacy against
COVID-19
• Antimicrobial Stewardship includes co-ordinated interventions to
improve antibiotic use by ensuring that patients received the
correct agent, at the correct dose for the optimal duration.

8. Wei W, Ortwine JK, Mang NS, et al. Limited Role for Antibiotics in COVID-19: Scarce Evidence of
Bacterial Coinfection. medRxiv 2020.06.16.20133181

13. • Out of 4200 patients, 152 patients had positive culture (either from respiratory
or blood culture or both)- 3.6%
• 91 patients had positive respiratory culture , 82 patients had positive blood
culture while 21 patients had both respiratory and blood culture

14. Sieswerda E, de Boer MGJ, Bonten MMJ, Boersma WG, Jonkers RE, Aleva RM, Kullberg BJ, Schouten JA,
van de Garde EMW, Verheij TJ, van der Eerden MM, Prins JM, Wiersinga WJ. Recommendations for
antibacterial therapy in adults with COVID-19 - an evidence based guideline. Clin Microbiol Infect. 2021
Jan;27(1):61-66. doi: 10.1016/j.cmi.2020.09.041.

15. Low risk of bacterial pneumonia (antibiotics not
needed or can be discontinued)
• Confirmed COVID-19 infection
• Procalcitonin <0.1 mcg/L
• Normal white blood cell (WBC) count
• Fever (T > 100.4 F)
• Negative sputum cultures
*Guidance for the Use of Empiric Antibiotics in Inpatient COVID-19
Pneumonia (https://www.nebraskamed.com)

16. Potential indications of bacterial pneumonia
(decide need for antibiotics based on patient-
specific factors)
• Procalcitonin >0.25 mcg/L
• Procalcitonin >0.5 mcg/L
• Leukocytosis
• Bacterial growth on respiratory tract culture
• Critically ill patients

17. When to start antibiotics?
• If there is confidence that the clinical features are typical for
COVID-19, it is reasonable not to start empirical antibiotics.
• Empirical antibiotics should be started if there is clinical
suspicion of bacterial infection, including characteristic
symptoms and localized chest findings. A neutrophil count
outside the normal range or lobar consolidation on chest
imaging may suggest a bacterial infection but their absence does
not exclude it.
*COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. London:
National Institute for Health and Care Excellence (UK); 2020 Oct 9. (NICE Guideline,
No. 173.)

18. • Start empirical antibiotic treatment as soon as possible after
establishing a diagnosis of pneumonia, and certainly within 4
hours.
• Do not wait for microbiological test results.
• Start treatment within 1 hour if the patient has suspected
sepsis and meets any of the high-risk criteria.

19. Antibiotic choice

21. COVID-19: ANTIBIOTIC MANAGEMENT IN AMBULATORY PATIENTS
Source Recommendations
WHO
April 11,
2020
Indications: Adults with pneumonia but no signs of severe
pneumonia and no need for supplemental oxygen may be isolated
in a community facility or home care and given an appropriate
antibiotic.
Pneumonia may be managed in an outpatient setting depending on
its severity, which may be determined by the combination of clinical
judgement and CURB-65 score.
Antibiotics are not indicated in patients with mild illness, defined
as upper respiratory viral infection presenting with fever, fatigue,
cough (with or without sputum production), anorexia, malaise,
muscle pain, sore throat, dyspnea, nasal congestion, or headache.
WHO
March
13,2021
Empiric antibiotic treatment should be based on the clinical diagnosis
(community acquired pneumonia, health care-associated
pneumonia [if infection was acquired in health care setting] or
sepsis), local epidemiology and susceptibility data, and national
treatment guidelines.

22. Source Recommendations
NICE
April 3
Oral antibiotics may be considered in patients with pneumonia or
presumed pneumonia in the case where objective diagnosis is not
possible who can or wish to be treated in the community if: the
likely cause is bacterial, or if it is unclear whether the cause is
bacterial or viral and symptoms are more concerning, or they
are at high risk for complications (ex. older, have a pre-existing
comorbidity such as immunosuppression or heart or lung disease,
or have a history of severe illness following lung infection).
When starting antibiotic treatment, the first-choice oral antibiotic is:
doxycycline 200 mg on the first day, then 100 mg once a day for 5
days in total (not in pregnancy). Alternative: amoxicillin 500 mg 3
times a day for 5 days [specific to ambulatory setting].
CDC
April 3
The CDC offers no guidance specific to the use of antibiotics in
COVID+ patients in the outpatient setting.

23. Treatment recommendation

24. Call for Stewardship: Clinical Implications

25. Call for Stewardship: Clinical Implications

26. Call for Stewardship: Shorter is Better !

27. Call for Stewardship: Research Needs

28. Summary

29. THANK YOU