Superinfection with difficult-to-treat bacteria in COVID-19 patients: a call for compliance with diagnostic and antimicr
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CE-RESEARCH LETTER TO THE EDITOR
Superinfection with difficult‑to‑treat bacteria in COVID‑19 patients: a call for compliance with diagnostic and antimicrobial stewardship Ombretta Para1 · Lorenzo Caruso1 · Mattia Ronchetti1 · Martina Finocchi1 · Stefano Guidi1 · Michele Spinicci2 Received: 13 June 2020 / Accepted: 10 October 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Dear Editor, By 24 August 2020, severe acute respiratory syndrome coronavirus (SARS-CoV)-2 has caused over 23 million cases and 800,000 deaths worldwide [1]. Based on the experience from other respiratory viral infections, such as pandemic influenza H1N1, SARS and Middle East respiratory syndrome (MERS), bacterial and/or fungal co-infections are likely to play a major role in increasing mortality [2–4]. Recent data from a systematic review reported a low proportion of pulmonary bacterial co-infection among COVID-19 patients [7% of all hospitalized patients and 14% of those admitted to intensive care unit (ICU)] [5]. However, COVID-19 patients with a co-infection are more likely to die than patients who do not have co-infections. A retrospective multicentre cohort study, indeed, found that secondary infections were present in 50% of non-survivor patients [6]. The World Health Organization (WHO) recommends against indiscriminate use of antibiotics in patients with coronavirus disease 2019 (COVID-19), unless there is clinical suspicion of a bacterial infection [7]. Similarly, the National Institute For Clinical Excellence (NICE) COVID19 guidance recommends to consider antimicrobial use only if a bacterial superinfection is likely and/or for patients with major co-morbidities who are at high risk of severe complications from untreated bacterial infections [8]. However, despite few reports of bacterial co-infection, an overuse of empirical antibiotics prescription in COVID-19 patients has been widely documented [9]. In a recent International Severe Acute Respiratory and Emerging Infections Consortium
* Lorenzo Caruso [email protected] 1
SOD Medicina Interna 1, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italia
SOD Malattie Infettive e Tropicali, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italia
2
(ISARIC) report, 62% of patients with COVID-19 had received antimicrobial therapy [10]. In this letter, we describe four cases of bacterial superinfection caused by difficult-to-treat pathogens, occurred in COVID-19 patients, to highlight the importance of a correct diagnostic work-up as a cornerstone to achieve aetiological diagnosis and to promote antimicrobial stewardship principles, also in a pandemic context. Data were retrieved from the electronic folds database of our Internal Medicine ward, in the Careggi University Hospital, a tertiary-care hospital in Florence, Italy, where more than 500 COVID-19 patients have been admitted to date. The four cases reported were observed in the period March 20 – May 1, 2020. In all cases, microbiological diagnosis of bacterial superinfection was achieved by bronchoscopy and b
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