Prospective audits, feedback improve antimicrobial treatment for patients with COVID-19
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Antibiotic prescribing was high among patients with COVID-19, but researchers found that antimicrobial stewardship programs with prospective audit and feedback helped optimize antibiotic treatments among these patients.
“Antibiotic overuse is common in COVID-19 patients. Despite physician awareness that bacterial coinfection rates are low in this population and that guidelines do not support antibiotic use, many are still reluctant to stop antibiotics, citing a lack of high-quality evidence,” Holly L. Hoang, MD, associate clinical professor in the division of infectious diseases at the University of Alberta Hospitals, told Healio.
“This study was meant to fulfill two objectives. First, we wanted to demonstrate that it is safe to stop antibiotics in this population and that prospective audit and feedback is an effective way to accomplish this. Second, given literature supporting prospective audit and feedback as an antimicrobial stewardship initiative is currently of low quality, we wanted to demonstrate that it is possible to design a high-quality study that confirms the safety of prospective audit and feedback,” she said.
Hoang, with Carlos Cervera, MD, and Justin C. Chen, MD, both of the University of Alberta Hospital’s division of infectious diseases, and colleagues, did so through COVASP — a prospective, pragmatic, noninferiority, small-unit, cluster-randomized trial comparing prospective audit and feedback plus standard of care with standard of care alone in adults admitted to three hospitals in Edmonton, Alberta, Canada, with COVID-19 pneumonia.
According to the study, all patients aged at least 18 years admitted to a designated study bed with microbiologically confirmed SARS-CoV-2 were included if they had an oxygen saturation of 94% or lower on room air, required supplemental oxygen or had chest imaging findings compatible with COVID-19 pneumonia. The primary outcome was clinical status on post-admission day 15.
In total, 866 patients were enrolled between March 1 and Oct. 29, 2021 — 457 into the prospective audit and feedback plus standard-of-care group, of whom 429 completed the study, and 429 into the standard-of-care group, of whom 404 completed the study.
The researchers found high overall antibiotic use among patients with COVID-19 (53%) despite low rates of bacterial coinfection (4%), resulting in what the researchers determined were high rates of guideline-discordant antibiotic prescribing (63%).
The study also revealed lower antibiotic use in the prospective audit and feedback plus standard-of-care group compared with standard of care alone (364.9 vs. 384.2 days per 1,000 patient days), although they found there was no difference in clinical status of patients at post-admission day 15 (interquartile range [IQR] 2-3 vs. IQR 2-4).
Hoang said that these findings show that antibiotic use is high among patients with COVID-19 and often does not follow guidelines. Because of this, she said “antimicrobial stewardship should remain a priority during pandemic settings.”
In a related commentary, Daniele Roberto Giacobbe, MD, PhD, and Matteo Bassetti, MD, PhD, both of the University of Genoa, wrote that this is the first randomized trial assessing the efficacy and safety of an antimicrobial stewardship intervention in patients hospitalized with COVID-19, and provides a higher than usual certainty of evidence that reducing antibiotic use in such patients is possible without substantial harm.
“Although not reaching the very high rates of antibiotic prescriptions registered at the beginning of the pandemic (70% to 100% of patients in most studies), the frequency of antibiotic use recorded by Chen and colleagues still remains uncomfortably high from an antimicrobial stewardship perspective,” they wrote. “Although some encouraging steps forward have been made, a lot of ground is still left to cover.”
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