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Q&A: COVID-19 superinfections and antimicrobial resistance

Cornelius (Neil) J. Clancy

Nosocomial superinfections, including ones that are resistant to antimicrobials, will likely develop in “an appreciable minority” of patients with severe COVID-19 infections, according to a commentary in Clinical Infectious Diseases, which notes that stewardship is “crucial” to reduce broad-spectrum antimicrobial use in patients who are hospitalized.

Healio spoke with Cornelius (Neil) J. Clancy, MD, associate professor of medicine and director of the extensively drug-resistant pathogen lab and mycology program at the University of Pittsburgh and coauthor of the commentary, about who is at highest risk for these infections, what types of infections are most concerning and what stewardship practices could be implemented to mitigate antimicrobial resistance, or AMR. – by Caitlyn Stulpin

Q: What patient groups are most at risk for “superinfections” related to COVID-19?

A: Patients who are critically ill and in intensive care units, particularly those receiving invasive mechanical ventilation, are at greatest risk.

Q: Which infections are you especially concerned about?

A: Pneumonias, especially ventilator-associated pneumonias. These will likely be caused by bacteria and, to a lesser extent, fungi that typically cause hospital-acquired infections.

Q: How could COVID-19 worsen the problem of AMR?

A: Hospitals in which antimicrobial resistant pathogens are a problem may see more infections by these pathogens. In most studies, almost all patients with COVID-19 in who are in the ICU receive antibiotics, which may select for resistant pathogens and/or promote the emergence of more resistance.

Q: What stewardship practices can be put into place to help mitigate this problem?

A: First, I want to note that most patients with COVID-19 will not develop secondary infections; if they are stable in the hospital, there is no need to give antibiotics. If some patients get started empirically on antibiotics because physicians are unsure whether a secondary infection is present, it is important to stop them if a secondary infection is not diagnosed. Finally, for those patients in whom a secondary infection is diagnosed, it is important that treatment be given with the narrowest spectrum antibiotic, for the shortest duration necessary.

Q: How could market reform and potentially congressional bills help to manage antimicrobial concerns related to COVID-19?

A: There are two types of legislation being considered in Congress. The DISARM Act would increase Medicare reimbursement to hospitals for use of antibiotics against antimicrobial-resistant pathogens. The PASTEUR Act would initiate a subscription or "Netflix" model, in which the government would pay a fee to ensure access to specified antibiotics in the event of need. This would be a so-called de-linkage model, in which reimbursement to companies is not based on the number of prescriptions ordered but rather the societal value of having active antibiotics against AMR pathogens. Both bills would help ensure that, if and when the nation needs antibiotics against a new superbug, these antibiotics will be available. The bills also mandate that hospitals run stewardship programs and collect antibiotic use data, thereby making participation in the models contingent upon responsible antibiotic prescribing.

Disclosure: Clancy reports receiving investigator-initiated research grants from Astellas, Cidara, Melinta and Merck for unrelated studies, serving on advisory boards or consulting for Astellas, Cidara, Merck, Needham & Company, Qpex, Scynexis, Shionogi and The Medicines Company and speaking at symposia sponsored by Merck and T2Biosystems.

Cornelius (Neil) J. Clancy

Nosocomial superinfections, including ones that are resistant to antimicrobials, will likely develop in “an appreciable minority” of patients with severe COVID-19 infections, according to a commentary in Clinical Infectious Diseases, which notes that stewardship is “crucial” to reduce broad-spectrum antimicrobial use in patients who are hospitalized.

Healio spoke with Cornelius (Neil) J. Clancy, MD, associate professor of medicine and director of the extensively drug-resistant pathogen lab and mycology program at the University of Pittsburgh and coauthor of the commentary, about who is at highest risk for these infections, what types of infections are most concerning and what stewardship practices could be implemented to mitigate antimicrobial resistance, or AMR. – by Caitlyn Stulpin

Q: What patient groups are most at risk for “superinfections” related to COVID-19?

A: Patients who are critically ill and in intensive care units, particularly those receiving invasive mechanical ventilation, are at greatest risk.

Q: Which infections are you especially concerned about?

A: Pneumonias, especially ventilator-associated pneumonias. These will likely be caused by bacteria and, to a lesser extent, fungi that typically cause hospital-acquired infections.

Q: How could COVID-19 worsen the problem of AMR?

A: Hospitals in which antimicrobial resistant pathogens are a problem may see more infections by these pathogens. In most studies, almost all patients with COVID-19 in who are in the ICU receive antibiotics, which may select for resistant pathogens and/or promote the emergence of more resistance.

Q: What stewardship practices can be put into place to help mitigate this problem?

A: First, I want to note that most patients with COVID-19 will not develop secondary infections; if they are stable in the hospital, there is no need to give antibiotics. If some patients get started empirically on antibiotics because physicians are unsure whether a secondary infection is present, it is important to stop them if a secondary infection is not diagnosed. Finally, for those patients in whom a secondary infection is diagnosed, it is important that treatment be given with the narrowest spectrum antibiotic, for the shortest duration necessary.

Q: How could market reform and potentially congressional bills help to manage antimicrobial concerns related to COVID-19?

A: There are two types of legislation being considered in Congress. The DISARM Act would increase Medicare reimbursement to hospitals for use of antibiotics against antimicrobial-resistant pathogens. The PASTEUR Act would initiate a subscription or "Netflix" model, in which the government would pay a fee to ensure access to specified antibiotics in the event of need. This would be a so-called de-linkage model, in which reimbursement to companies is not based on the number of prescriptions ordered but rather the societal value of having active antibiotics against AMR pathogens. Both bills would help ensure that, if and when the nation needs antibiotics against a new superbug, these antibiotics will be available. The bills also mandate that hospitals run stewardship programs and collect antibiotic use data, thereby making participation in the models contingent upon responsible antibiotic prescribing.

Disclosure: Clancy reports receiving investigator-initiated research grants from Astellas, Cidara, Melinta and Merck for unrelated studies, serving on advisory boards or consulting for Astellas, Cidara, Merck, Needham & Company, Qpex, Scynexis, Shionogi and The Medicines Company and speaking at symposia sponsored by Merck and T2Biosystems.

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