Q&A: Antibiotic Stewardship Takes Step Backward During Pandemic

By John Palmer

So-called “superbugs” that are becoming resistant to antibiotics are continuing to emerge in the healthcare environment, and while infection control professionals are fighting a valiant battle to control these strengthening infectious organisms, there are indications that some of the germs may not be able to be controlled.

Efforts to curb overuse of antibiotics have taken a step backward due to COVID-19, according to some researchers.

A November 2019 report from the CDC blamed almost 3 million infections and 35,000 deaths a year from antibiotic-resistant bacterial and fungal infections. The problem has been so widespread in U.S. hospitals that regulatory agencies such as The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) have begun requiring hospitals to establish tighter antimicrobial stewardship programs in an attempt to lower the number of infections.

But in the wake of the current pandemic, some researchers have found that patients with clearly defined viral pneumonia related to COVID-19 are being treated with antibiotics, even though it is well established that viral infections do not respond to these drugs.

In fact, a study published May 2 in the journal Clinical Infectious Diseases found that 72% of 2,010 COVID-19 patients received antibiotics in the hospital, while only 8% of those patients suffered bacterial and fungal co-infection.

Trevor Van Schooneveld, MD, is a board member of the Society for Healthcare Epidemiology of America and medical director of the Antimicrobial Stewardship program at the Nebraska Medical Center. In this Q&A, he spoke with PSQH about the growing problem of treating COVID-19 patients with antibiotics.

PSQH: It’s been reported that patients with clearly defined viral pneumonia related to COVID-19 are being treated with antibiotics, even though it is well established that viral infections do not respond to these drugs. Where is this happening the most, and why, in your opinion? In the absence of another vaccine or treatment, is this being done as a shot in the dark?

Trevor Van Schooneveld: It’s difficult to define where this [is] happening the most, but two recent papers suggested [it’s] happening quite frequently. I think the reason this is happening is that clinicians feel the need to do something. Just like we want to give medications like hydroxychloroquine, which may or may not help, we want to give antibiotics even though they may not help. Unfortunately, medications that do not provide benefit will only harm patients.

PSQH: While COVID-19 is viral and might not respond to these drugs, could there be an argument made for treating patients with antibiotic drugs to help prevent or mitigate other conditions that may present along with, or as a result of treatment for COVID-19? Specifically, with the fact that many patients need to be on a ventilator, can’t many bacterial infections be transmitted using these machines and therefore antibiotics [become] a way to reduce further life-threatening infections?

Van Schooneveld: Bacterial infections at the time of COVID diagnosis appear to be quite rare, but patients who developed severe COVID infections may be on the ventilator for a prolonged period of time. Anyone on a ventilator for [a] prolonged period of time is at risk of developing a bacterial pneumonia. Antibiotics don’t generally prevent pneumonia for patients on [a] ventilator and [are] not recommended in any guideline as a strategy to prevent pneumonia. In fact, we have a number of studies that suggest using antibiotics in this way may harm patients and make it much more likely that when they do develop an infection, it will be with a bacteria resistant to antibiotics.

PSQH: In your opinion, what is the status of antibiotic stewardship in U.S. hospitals in 2020? Are things getting better or worse, and what sort of education or other intervention is needed to get the message out to healthcare workers that we are over-prescribing antibiotic drugs?

Van Schooneveld: Before the COVID pandemic, antibiotic stewardship, I would say, was generally improving in U.S. hospitals. Stewardship programs are now required in both hospitals and long-term care facilities by both governmental regulatory authorities (CMS) and accrediting organizations (Joint Commission and others). Unfortunately, events like the COVID pandemic can set these efforts back a bit as we lose focus on one problem and deal with another. I think a key message is something we’ve been saying for a number of years, which is that viral infections don’t get better with antibiotics. Providing antibiotics to people for viral infections can’t help them and can only harm them. While clinicians would agree with that statement, they have to ensure they apply it in their practice.

PSQH: In 2019, CMS released new CoPs for hospitals [including a goal] to reduce antibiotic use by 20% by 2020. Have you seen any evidence that this new guidance has worked, or has the following of this sort of guidance gone out the door in the wake of COVID-19?

Van Schooneveld: I think the CMS CoPs were definitely needed and setting goals to reduce antibiotic use may be helpful. As these regulations just went into effect, it is difficult to measure their impact. It has been encouraging that the number of hospitals who have stewardship programs has been increasing over the last few years. I think the requirement will have a significant influence on all facilities, and in particular on smaller hospitals, which in the past may not have devoted resources to developing stewardship programs. I am hopeful that the gains we have seen won’t be thrown out with the COVID pandemic, although it has distracted people from this issue and also redirected many resources. I think in the short term, COVID has resulted in some clinicians using antibiotics in ways that are not ideal, and hopefully as things settle down, we can continue to work to improve how we manage patients.

PSQH: Do you have any advice for hospitals looking to improve their antibiotic stewardship during this difficult time when personnel are already overwhelmed?

Van Schooneveld: Hospitals should use the same processes to improve antibiotic usage that they’ve used in the past. Those with stewardship programs should continue to assist with the management of antibiotics, even in COVID patients. The variety of methodologies for doing this range from guidelines to rapid diagnostics to audit and feedback. These strategies, which have proven to be effective in the past, should continue to be effective in the setting of COVID.

I think the most effective thing may be making clinicians comfortable with not giving antibiotics. It is important that clinicians understand the nature of COVID and how to manage it, and that antibiotics are not generally indicated in its treatment unless there is clear evidence of a secondary bacterial infection.

PSQH: What are some steps that can be taken to educate staff and hold them accountable? Should we even be thinking about maintaining proper stewardship during a pandemic?

Van Schooneveld: We should definitely be thinking about maintaining proper stewardship during this pandemic. The issue with antibiotic resistance is ongoing and won’t go away because of COVID. Excessive and unnecessary antibiotic use is likely to exacerbate it. This is why it’s important to support antibiotic stewardship programs by providing personnel and resources to effectively implement strategies to [improve] antibiotic use.

The same processes that have been in place to improve antibiotic use in the past should continue to be utilized. They should not be thrown out the window just because of the COVID pandemic. We need to continue to do what is best for our patients, which may mean not responding to the urge to do “something,” especially when that something has no evidence of benefit.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.