Antimicrobial stewardship in ICUs during the COVID-19 pandemic: back to the 90s?
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Antimicrobial stewardship in ICUs during the COVID‑19 pandemic: back to the 90s? Jan J. De Waele1* , Lennie Derde2,3 and Matteo Bassetti4 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
SARS-CoV-2 infection has arguably been one of the most significant challenges of health care systems around the world in over a century. The coronavirus disease 2019 (COVID-19) lead to a massive increase in demand for acute care beds in many countries [1]. Here, we focus on one of the unintended side effects of the surge in COVID19 patients in the intensive care unit (ICU). Under these circumstances, it became challenging to uphold basic principles in patient management. During the pandemic, the goals of antimicrobial stewardship programs (ASP) remain unchanged. First, limiting antimicrobial exposure to prevent antimicrobial resistance in ventilated patients with prolonged ICU stay is highly relevant in the patient admitted with COVID-19. Second, avoiding toxicity is a particular concern, as many of the antivirals and antibiotics can have severe side effects and interactions. Finally, given the high mortality, improving the outcome of the patient with COVID-19 is central. Remarkably, as the pandemic spread, we have been ignoring many of the antimicrobial stewardship (AMS) strategies that were developed and implemented in the past decade. Although there was no evidence that bacterial superinfection was a major problem in patients admitted to the ICU—there was compelling evidence that the inflammatory response was the main driver of disease severity—empirical administration of antibiotics was widespread [2]. This was also advocated by international guidelines [3], based on extrapolation from other viral diseases e.g., influenza, while for coronavirus infections in the past, superinfection occurred in only 14% of patients during the total ICU stay [4]. When bacterial pneumonia *Correspondence: [email protected] 1 Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000 Gent, Belgium Full author information is available at the end of the article
develops, this is typically later in the clinical course, presenting as late-onset ventilator-associated pneumonia [5]. A recent meta-analysis found that only 3.5% of all COVID19 patients present with co-infection, and 14% develop infections at a later stage; in critically ill patients, an estimated 8% developed infections (including co-infection and secondary infection) [6]. Most of the data in this metaanalysis come from centers in China and it is not clear how this applies to other patient populations and settings. Admittedly the situation was challenging. Patients were in the ICU and ventilated for much longer than usual, with an inherent risk of nosocomial infections. The diagnostic approach for bacterial infection was difficult, with the inflammatory response in COVID-19 mimicking the clinical construct of bacterial infection. Another factor was the potential risk of transmitting the virus by performing i
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