US hospital data show nearly 80% of COVID-19 patients get antibiotics

Nearly 80% of US patients hospitalized for COVID-19 received antibiotics from March through October 2020, researchers from the Centers for Disease Control and Prevention (CDC) reported yesterday in Open Forum Infectious Diseases.

Using data from the Premiere Healthcare Database Special COVID-19 Release, the researchers found that 77.3% of 213,338 COVID-19 patients treated at 716 US hospitals received at least one antibiotic during their stay, and 81.3% of those who received an antibiotic were started on admission.

The antibiotic use rate in COVID-19 patients was 889 days of therapy (DOT) per 1,000 patient-days (PD), with a rate of 932 DOT/1,000 PD among patients admitted to critical care and 988 DOT/1,000 PD among those requiring invasive mechanical ventilation. The proportion of COVID-19 patients receiving antibiotics was lower during September through October (71.3%) than during March through May (80.2%).

Approximately half (49.7%) of COVID-19 patients received ceftriaxone, 44.3% received azithromycin, and 35.6% received a combination of both. Larger proportions of patients admitted to critical care or requiring invasive mechanical ventilation received vancomycin, cefepime, piperacillin-tazobactam, and meropenem.

But the data also showed that median hospital-wide antibiotic use was significantly lower during March through October 2020 compared with March through October 2019, falling from 932 to 917 DOT/1,000 PD.

“Antibiotic stewardship programs can leverage their infrastructure to address challenges that the COVID-19 pandemic has presented to healthcare professionals in the hospital setting,” the study authors wrote. “Ensuring resiliency and continuity of hospital stewardship programs is critical to optimize the treatment and outcomes of all inpatients and those with COVID-19.”
Jun 3 Open Forum Infect Dis abstract

Surveillance data indicate potentially improper treatment for candidemia

Analysis of surveillance data showed that a substantial proportion of candidemia patients initially received fluconazole, resulting in potentially inappropriate treatment of the opportunistic fungal infection, US researchers reported yesterday in Clinical Infectious Diseases.

In 2016, because of rising levels of fluconazole resistance, the increasing frequency of non-albicans Candida species (which tend to be more resistant to antifungals), and evidence that echinocandins are more effective than fluconazole, the Infectious Diseases Society of America (IDSA) changed its treatment guidelines to recommend echinocandins for initial treatment of candidemia. To assess adherence to those guidelines, researchers with the Emerging Infections Program, a collaboration between the CDC and state health departments, analyzed candidemia surveillance data from nine US sites. To identify instances of potentially inappropriate treatment, they compared the first antifungal drug received with species and antifungal susceptibility testing (AFST) results.

The analysis found that 2,415 candidemia cases occurred among 2,271 adult patients. Of these patients, 1,835 received an antifungal drug, with 68.6% receiving an echinocandin and 29.6% receiving fluconazole. Over half (56%) of the patients treated with fluconazole grew a non-albicans species, and among 265 patients who were treated with fluconazole and had AFST results, 10.6% had a fluconazole-resistant isolate.

Multivariable logistic regression modeling found that cirrhosis, recent hospitalization, and surveillance site were the only factors significantly associated with receipt of an echinocandin versus fluconazole, with cirrhosis patients more than twice as likely to receive an echinocandin (adjusted odds ratio, 2.06; 95% confidence interval, 1.29 to 3.29). In addition, patients at certain surveillance sites had over twice the odds of receiving an echinocandin compared with other sites, suggesting that geographic location and regional practices play a stronger role in initial candidemia therapy.

“Our findings highlight opportunities for closer adherence to IDSA guidelines on antifungal drug selection and AFST utilization, as well as the need for improved candidemia diagnostic tools,” the study authors concluded. “Further research regarding how clinicians choose antifungal drugs for candidemia and barriers to use of IDSA guidelines is also needed.”
Jun 3 Clin Infect Dis abstract