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Bacterial Co-Infection with COVID-19, 11/19 · The SHEA Podcast

• 0:10
  SPEAKER_03: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_03: I'm Dr.
• 0:23
  SPEAKER_03: Jennifer Blumenthal, instructor in the Division of Critical Care Medicine and the Division of Pediatric Infectious Diseases at Boston Children's Hospital and Harvard Medical School, and I will serve as the moderator.
• 0:33
  SPEAKER_03: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:42
  SPEAKER_03: Shay is excited to launch this podcast to the COVID-19 updates, What We Know Now, and today's discussion will focus on bacterial coinfection with COVID-19.
• 0:51
  SPEAKER_03: Our speakers today are Dr.
• 0:53
  SPEAKER_03: Justina McGregor, Associate Professor in the College of Pharmacy at Oregon State University, Dr.
• 0:58
  SPEAKER_03: Kara Varley, Infectious Diseases Fellow at Oregon Health and Science University School of Medicine and the Oregon Health and Science University, Portland State University School of Public Health, and Dr.
• 1:08
  SPEAKER_03: Holly Villamania, faculty member at Oregon Health and Science University School of Medicine.
• 1:14
  SPEAKER_03: Thank you for joining us today.
• 1:16
  SPEAKER_03: Before we start our discussion, I would like to turn it over to Dr.
• 1:18
  SPEAKER_03: Han Rahan to get us started with a brief news and guidance update for the week.
• 1:23
  SPEAKER_00: Thank you.
• 1:24
  SPEAKER_00: As of November 17, 2020, there have been 54,771,888 confirmed cases of COVID-19, including 1,324,249 deaths reported to the World Health Organization.
• 1:40
  SPEAKER_00: Amid rising numbers of coronavirus cases throughout the world, there's some good news this week.
• 1:45
  SPEAKER_00: Pfizer and BioNTech announced today that after conducting the final efficacy analysis in their ongoing phase three study, their messenger RNA-based COVID-19 vaccine candidate met all of the study's primary efficacy endpoints.
• 1:59
  SPEAKER_00: Analysis of the data indicates a vaccine efficacy rate of 95%.
• 2:03
  SPEAKER_00: The first primary objective analysis is based on 170 cases of COVID-19 as specified in the study protocol, of which 162 cases of COVID-19 were observed in the placebo group versus eight cases in the vaccine group.
• 2:17
  SPEAKER_00: Efficacy was consistent across age, gender, race, and ethnicity demographics.
• 2:22
  SPEAKER_00: The observed efficacy in adults over 65 years of age was 94%.
• 2:28
  SPEAKER_00: To date, the data monitoring committee for the study has not reported any serious safety concerns related to the vaccine.
• 2:34
  SPEAKER_00: The only grade three adverse events greater than or equal to 2% in frequency after the first or second dose was fatigue at 3.8% and headache at 2% following dose 2.
• 2:44
  SPEAKER_00: The companies plan to submit within days to the Food and Drug Administration for an emergency use authorization, and the companies expect to produce globally up to 50 million vaccine doses in 2020 and up to 1.3 billion doses by the end of 2021.
• 3:00
  SPEAKER_00: Another candidate vaccine also announced promising results this week.
• 3:03
  SPEAKER_00: On November 16th, Moderna announced that the independent NIH-appointed data safety monitoring board for the phase three study of its vaccine candidate against COVID-19 informed Moderna that the trial met the statistical criteria pre-specified in the study protocol for efficacy with a vaccine efficacy of 94.5%.
• 3:22
  SPEAKER_00: The study, known as the COVID study, enrolled more than 30,000 participants in the U.S.
• 3:26
  SPEAKER_00: This first interim analysis was based on 95 cases, of which 90 cases of COVID-19 were observed in the placebo group versus five cases observed in the vaccine group, resulting in a point estimate of vaccine efficacy of 94.5%.
• 3:39
  SPEAKER_00: A secondary endpoint analyzed severe cases of COVID-19 and included 11 severe cases in this first interim analysis.
• 3:46
  SPEAKER_00: All 11 cases occurred in the placebo group and none in the vaccine group.
• 3:50
  SPEAKER_00: The interim analysis included a concurrent review of the available phase three COVID study safety data by the DSMB, which did not report any significant safety concerns.
• 4:00
  SPEAKER_00: The British Medical Journal website highlights a study currently available on a preprint server of young low-risk patients with ongoing symptoms of COVID-19 demonstrating signs of damage to multiple organs four months after initially being infected.
• 4:13
  SPEAKER_00: Initial data from 201 patients suggest that almost 70% had impairments in one or more organs four months after their initial symptoms of SARS-CoV-2 infection.
• 4:22
  SPEAKER_00: The prospective cover scan study examined the impact of long COVID across multiple organs in low-risk people who are relatively young and had no major underlying health problems.
• 4:31
  SPEAKER_00: Assessment was done using results from magnetic resonance image scans, blood tests, and online questionnaires.
• 4:37
  SPEAKER_00: The research has not yet been peer-reviewed and could not establish a causal link between organ impairment and infection, but the authors said the results had implications not only for the burden of long COVID, but also public health approaches which have assumed low risk in young people with no comorbidities.
• 4:51
  SPEAKER_00: The American Academy of Pediatrics reports that as of November 12th, over 1 million children have tested positive for COVID-19 since the onset of the pandemic.
• 4:59
  SPEAKER_00: Children represented 11.5% of all cases in states reporting cases by age.
• 5:04
  SPEAKER_00: A smaller subset of states reported on hospitalizations and mortality by age.
• 5:08
  SPEAKER_00: The available data indicated that COVID-19 associated hospitalization and death is uncommon in children.
• 5:14
  SPEAKER_00: The number of new child COVID-19 cases reported this week, nearly 112,000, is by far the highest weekly increase since the pandemic began.
• 5:22
  SPEAKER_00: At this time, it appears that severe illness due to COVID-19 is rare among children.
• 5:26
  SPEAKER_00: However, there's an urgent need to collect more data on longer-term impacts on children, including ways the virus may harm the long-term physical health of infected children as well as its emotional and mental health effects.
• 5:37
  SPEAKER_00: And that's the news this week.
• 5:39
  SPEAKER_03: Thank you so much for the update.
• 5:40
  SPEAKER_03: I now want to move into the discussion with our guests.
• 5:43
  SPEAKER_03: So we'll get started with a few questions.
• 5:46
  SPEAKER_03: Why is antimicrobial stewardship a concern during the COVID-19 pandemic?
• 5:51
  SPEAKER_04: Thank you, Dr.
• 5:51
  SPEAKER_04: Blumenthal.
• 5:52
  SPEAKER_04: The pandemic has had broad impacts on both infection prevention and antimicrobial stewardship.
• 5:57
  SPEAKER_04: Early in the pandemic, our hospitalized patient populations fundamentally shifted with a cessation of elective surgeries and a shift towards reduced admissions for patients that could be safely treated as outpatients.
• 6:08
  SPEAKER_04: Our management of patients shifted as our understanding of SARS-CoV-2 symptoms and disease course increased and as testing became more available with reduced turnaround times.
• 6:17
  SPEAKER_04: Still, with so many changes and new strains on the healthcare workforce, antimicrobial stewardship has really suffered.
• 6:23
  SPEAKER_04: With limited effective treatment options, providers look for what they can treat.
• 6:27
  SPEAKER_04: And this leads to increased culturing, for example, of tracheal aspirates, which may increase detection of common flora.
• 6:34
  SPEAKER_04: This in turn contributes to increased and excess antibiotic utilization.
• 6:38
  SPEAKER_04: Hence, understanding the risk of secondary bacterial infection is critical to both effective treatment of COVID patients and prudent antibiotic use.
• 6:46
  SPEAKER_03: Those are great points.
• 6:47
  SPEAKER_03: So what types of bacterial coinfections are most commonly seen in patients who have already been diagnosed with COVID-19?
• 6:54
  SPEAKER_02: So most of the current data that we have is on pneumonia and bacteremia.
• 6:59
  SPEAKER_02: Unfortunately, many of the studies published so far don't really distinguish between colonization and those with true bacterial infections, which can also become challenging in the setting of retrospective analyses and the symptoms of COVID.
• 7:10
  SPEAKER_02: But this can make interpretation of those results pretty challenging.
• 7:13
  SPEAKER_02: However, the frequency of secondary infections is pretty low, less than 5% in most of the studies we've looked at so far.
• 7:19
  SPEAKER_02: Still, for hospitalized COVID patients who are decompensating clinically, we often become desperate to intervene.
• 7:24
  SPEAKER_02: So antibiotics are often initiated, even with minimal evidence, despite side effects and toxicity.
• 7:29
  SPEAKER_02: And I think this stems from most of our clinical experience with severe respiratory viruses coming from influenza, where all of us are taught very early on that the mortality is really due to bacterial co-infections and it's something we can treat, where this has really required a shift in thinking with COVID-19, which is difficult for providers, especially when we don't really have a lot of other therapeutic options.
• 7:50
  SPEAKER_03: That's so true.
• 7:51
  SPEAKER_03: And as a critical care physician, I can feel that urgency to try to treat something.
• 7:56
  SPEAKER_03: And so it's very helpful to understand these risks.
• 7:59
  SPEAKER_03: So, what is the risk of bacterial pneumonia in a patient with COVID-19?
• 8:04
  SPEAKER_01: Based on the data we have so far, we think the risk is actually pretty low.
• 8:08
  SPEAKER_01: So Lehman and colleagues at the University of Chicago published a retrospective review in clinical infectious diseases, and they looked at 321 patients admitted with COVID-19 in March and April.
• 8:20
  SPEAKER_01: And overall, these patients had a lot of testing for bacterial pneumonia.
• 8:24
  SPEAKER_01: 91% of them had bacterial and viral PCR pathogen panels, 75% had strep and legionella urine antigen testing, and 21% had respiratory cultures.
• 8:36
  SPEAKER_01: And out of all of that testing, only seven patients, so about 2%, were actually diagnosed with a bacterial pneumonia.
• 8:42
  SPEAKER_01: The strengths of this particular study were that it was designed to capture early bacterial pneumonias by only looking at testing done within the first five days of admission.
• 8:52
  SPEAKER_01: And it also only included patients that ID doctors felt had clinically significant coinfection after reviewing the chart data.
• 8:59
  SPEAKER_01: And this study really demonstrated the low incidence of bacterial pneumonia in COVID-19 patients early in their hospital courses and underscored the need for both diagnostic and antibiotic stewardship early in the course of the disease.
• 9:12
  SPEAKER_01: We do also have some data comparing the incidence of bacterial pneumonia in COVID-19 to influenza.
• 9:18
  SPEAKER_01: Young and colleagues in the UK recently published a letter to the editor in Journal of Infection.
• 9:24
  SPEAKER_01: And in that letter, they compared bacterial coinfection rates in ventilated patients, and they included 24 people with influenza and 36 with COVID-19.
• 9:33
  SPEAKER_01: And within 48 hours of ICU admission, 58% of the patients with influenza were diagnosed with a bacterial coinfection compared to only 8% of the patients with COVID-19, which was a pretty significant difference.
• 9:46
  SPEAKER_01: It is important to note that there was no statistically significant difference in coinfection rates after 48 hours of ICU admission, but this study again demonstrated that patients with COVID-19 probably have relatively low rates of bacterial pneumonia early in their hospitalizations.
• 10:03
  SPEAKER_02: This is very similar to what we've seen here in the US as well.
• 10:06
  SPEAKER_02: Vaughn and colleagues published the results of a very large multi-center cohort study in clinical infectious diseases, where they used data from 38 Michigan hospitals to look for early infections, and these were within three days of admission in patients hospitalized with COVID-19.
• 10:20
  SPEAKER_02: And out of all of these patients, they found 1700, only 29 or 1.7% had a bacterial respiratory pathogen identified.
• 10:28
  SPEAKER_02: And they excluded a lot of the colonizers from positive cultures, used urine antigen tests, and then PCR for only our mycoplasma and chlamydia pneumonia.
• 10:37
  SPEAKER_02: So many of the patients with colonizers were excluded in this setting.
• 10:41
  SPEAKER_02: Another study from Norian colleagues published in infection control and hospital epidemiology.
• 10:46
  SPEAKER_02: This was done in New York City, identified 91 bacterial pneumonias out of about 4,000 patients.
• 10:51
  SPEAKER_02: This was both adult and pediatric patients, and only 2.1% had any bacterial coinfections at the time.
• 10:57
  SPEAKER_02: Another important thing from the study is that the time between the positive COVID-19 test and respiratory culture was about six days.
• 11:03
  SPEAKER_02: And over 90% of these patients were admitted to ICUs or were intubated.
• 11:07
  SPEAKER_02: So this is raising the concern that most of these may be hospital-associated infections as opposed to community acquired.
• 11:14
  SPEAKER_04: Yes, so overall, these data suggests that newly admitted COVID-19 patients do not require empiric therapy for community-associated pneumonia or CAP.
• 11:23
  SPEAKER_04: And this is unlike how we typically manage patients admitted with influenza.
• 11:26
  SPEAKER_04: However, these COVID patients are still at risk for healthcare associated infections, just as any other hospitalized patient.
• 11:33
  SPEAKER_04: While the risk of healthcare associated pneumonia or HAP is relatively low among COVID patients, it is still possible.
• 11:38
  SPEAKER_04: When antibiotics are initiated in suspicion of secondary HAP, it is important to keep in mind that high white blood cell counts or high procalcitonin alone may not be sufficient evidence to continue therapy if cultures are negative and radiology is inconclusive.
• 11:53
  SPEAKER_03: That is such interesting information.
• 11:55
  SPEAKER_03: I think that we will all take that forward and be more mindful of our antibiotic use.
• 12:00
  SPEAKER_03: So when pneumonia is present, what pathogens do we expect to see in the COVID-19 patients?
• 12:07
  SPEAKER_01: So going back to the letter to the editor published by Young and colleagues, they found 13 bacterial coinfections in people with COVID-19 who'd been in the ICU for more than 48 hours.
• 12:19
  SPEAKER_01: And in the letter, the authors wrote that 12 of those 13 infections were caused by gram-negative bacteria commonly associated with ventilator-associated pneumonias or catheter-related bloodstream infections.
• 12:31
  SPEAKER_01: And then in the single center study published by Norian colleagues in New York City, they reported that out of 152 patients, 3.6% had a positive blood or urine culture that the authors deemed to be a true bacterial coinfection.
• 12:46
  SPEAKER_01: And when we look specifically at the positive respiratory cultures, the median time elapsed between positive COVID testing and the positive respiratory culture was six days.
• 12:56
  SPEAKER_01: So again, we're really looking at patients well into their hospitalizations.
• 13:00
  SPEAKER_01: And in this cohort, Staph aureus was the most common pathogen, followed by Pseudomonas, Klebsiella, Enerobacter, any coli species.
• 13:08
  SPEAKER_01: So I think the upshot of both of these studies is that while a lot of things have changed this year, this is not something that's very different.
• 13:16
  SPEAKER_01: And that when we see bacterial coinfections in these patients, we're really probably looking at the usual nosochomial pathogens.
• 13:23
  SPEAKER_01: The other thing to add is that we haven't seen as many of these early bacterial coinfections in the literature.
• 13:30
  SPEAKER_01: So there's not quite as much data on the microbiology of community or early onset coinfection.
• 13:35
  SPEAKER_01: In the University of Chicago study that looked at patients admitted for less than five days, of the seven bacterial infections diagnosed, one patient had Staph aureus, one patient had mixed Staph aureus and proteus, there was a Bordatella species diagnosed on PCR testing, and then the other four patients had positive urine strep antigen testing.
• 13:56
  SPEAKER_01: So this suggests to me that if we're seeing a community-acquired bacterial coinfection in a patient with COVID-19, we're also probably dealing with one of the common community-acquired pneumonia pathogens, but we don't have quite as much data there.
• 14:10
  SPEAKER_03: Okay, well, that is reassuring to know that we can treat at least the bacterial superinfections, which are low as sort of our usual bacterial superinfections for viral disease.
• 14:20
  SPEAKER_03: So moving into the risk of bacteremia, what have we seen in the literature that the risk of bacteremia is in patients with COVID-19?
• 14:28
  SPEAKER_04: Siploveda and colleagues published a study in the Journal of Clinical Microbiology where they compared the frequency of positive blood cultures in COVID and non-COVID patients from New York City hospitals early in the course of the pandemic.
• 14:40
  SPEAKER_04: They evaluated over 88,000 blood cultures from roughly 28,000 patients.
• 14:44
  SPEAKER_04: The frequency of blood culture positivity was significantly lower in the COVID patients at 3.8% compared to the non-COVID patients at 7.1%.
• 14:53
  SPEAKER_04: Even then, the cultures from the COVID patients included a higher proportion that likely represented contamination with common skin flora.
• 15:01
  SPEAKER_04: And once these contaminants were excluded, the rate of bacteremia among the COVID patients was only 1.6%.
• 15:08
  SPEAKER_04: The most frequent causes of true bacteremia in these patients were E.
• 15:11
  SPEAKER_04: coli, Staph aureus, clebsiella pneumoniae, and enterbacter Cloacae complex.
• 15:16
  SPEAKER_04: And this is similar to what was observed in the comparative group of the non-COVID patients.
• 15:21
  SPEAKER_02: And there's two additional studies that support lower rates of bacteria as well.
• 15:25
  SPEAKER_02: One is the large study out of Michigan looking at the early community-acquired infections in about 1,700 hospitalized COVID-19 patients.
• 15:32
  SPEAKER_02: And only 31 or 1.8% had positive blood cultures in those first three days of hospitalization.
• 15:39
  SPEAKER_02: There's another large study out of New York City.
• 15:41
  SPEAKER_02: It's again found 1.9% or 82 out of about 4,000 patients with positive blood cultures.
• 15:46
  SPEAKER_02: And once again, these were all positive around day seven was the median time.
• 15:50
  SPEAKER_02: And 44 of these patients or 54% had a documented venous catheter at the time of bacteremia.
• 15:55
  SPEAKER_02: Once again, raising the slim concern for a healthcare associated infection.
• 15:59
  SPEAKER_03: Great.
• 16:00
  SPEAKER_03: So low rates of bacteria as well.
• 16:02
  SPEAKER_03: So from a stewardship perspective, since you are all antimicrobial stewardship experts, what is the concern regarding bacteremia in COVID patients?
• 16:11
  SPEAKER_04: Overall, bacteremia does not seem to be a common among patients with COVID.
• 16:16
  SPEAKER_04: However, the concern over bacteremia can drive increases in blood culture ordering.
• 16:20
  SPEAKER_04: The study that I mentioned earlier from Sapalveda and colleagues reported that the volume of blood cultures ordered increased by almost 35% during that early pandemic period, and this strained the capacity of their laboratory and ultimately was a motivating factor for the study they performed.
• 16:35
  SPEAKER_04: This highlights the need for diagnostic stewardship in concert with antibiotic stewardship.
• 16:40
  SPEAKER_04: Excessive ordering of blood cultures or other rapid tests when not sufficiently warranted can contribute to diagnostic uncertainty and ultimately unnecessary antibiotic use, in addition to placing undue burden on the laboratories.
• 16:52
  SPEAKER_03: Yes, and the labs are definitely running at capacity right now.
• 16:55
  SPEAKER_03: So what patients are at greatest risk of bacterial coinfection?
• 17:00
  SPEAKER_01: So the study from Vaughn and colleagues out of Michigan compared patients in that cohort who were diagnosed with a community acquired bacterial coinfection, and there were 59 people to those who did not have coinfection.
• 17:12
  SPEAKER_01: And in the analysis, patients with COVID-19 were more likely to have a bacterial coinfection if they were older, had a lower BMI, had kidney disease, were admitted from a skilled nursing facility, were more severely ill, or had signs of bacterial infection, like an increased white blood cell count.
• 17:30
  SPEAKER_01: I also think as clinicians are triaging the likelihood of a bacterial co-infection, it's really important to be mindful of the usual risks that we worry about for hospital-acquired infection.
• 17:41
  SPEAKER_01: So devices like ventilators, foley catheters, and central lines, I think all of our usual risk factors are still very important here.
• 17:50
  SPEAKER_03: Now that you've shared with us how low the incidence of pneumonia and bacteremia are in COVID-19 patients, how big is the stewardship problem?
• 17:57
  SPEAKER_03: How frequently are antibiotics initiated in patients with COVID-19?
• 18:01
  SPEAKER_02: So this is a really huge problem.
• 18:03
  SPEAKER_02: Empiric antibiotics are being initiated pretty frequently.
• 18:06
  SPEAKER_02: About 50 to 70% of patients in the setting of very few bacterial coinfections are being prescribed antibiotics.
• 18:12
  SPEAKER_02: And the data are pretty consistent across multiple studies.
• 18:16
  SPEAKER_02: Going back to the large Michigan study done by Vaughn and colleagues focusing on early infections, so within three days of admission, and antibiotic initiation within two days of admission, about 56.6% of patients, or 965 out of 1,700, were prescribed empiric antibiotics, whereas only 3.5% of COVID-19 patients had a confirmed community onset coinfection.
• 18:38
  SPEAKER_02: They did note that empiric antibiotics had decreased for those admitted later in the COVID surge, so hopefully the trend will continue to improve as the pandemic continues.
• 18:46
  SPEAKER_02: Another study done out of New York City looking at 5,800 COVID-19 patients, 4,000 received at least one antibiotic dose, and that was about 71% of the population.
• 18:56
  SPEAKER_02: Of those with infections, 70% also received greater than three antibiotic classes, which really raises concern for toxicity in this setting.
• 19:04
  SPEAKER_02: And then there was an additional review of nine studies of co-infections with COVID-19 done by Rossin and colleagues.
• 19:10
  SPEAKER_02: Most of these were from China and two were from the United States, but they found that about 8% of co-infections were seen.
• 19:16
  SPEAKER_02: However, 72% of patients received antibiotics.
• 19:19
  SPEAKER_02: And so this is just not a trend that we're seeing in the US.
• 19:23
  SPEAKER_03: So, how can we apply what we know now in the clinical setting and what actionable steps can be taken by antimicrobial stewardship teams?
• 19:31
  SPEAKER_02: So, in most cases of COVID-19, when patients are febrile and maybe requiring some oxygen but otherwise hemodynamically stable, antibiotics do not need to be started.
• 19:41
  SPEAKER_02: However, there are some situations where it's very appropriate to start antibiotics empirically, but we need to ensure that we are evaluating their ongoing need and the toxicity daily in our patients.
• 19:50
  SPEAKER_02: So to illustrate this point better, let's consider kind of two stewardship case examples.
• 19:54
  SPEAKER_02: First, let's consider a case where antibiotics are initiated prior to the COVID test results coming back.
• 20:00
  SPEAKER_02: We have a 67-year-old gentleman.
• 20:02
  SPEAKER_02: He has COPD, type 2 diabetes with some chronic kidney disease, presents to the emergency department with shortness of breath.
• 20:08
  SPEAKER_02: He was found to be hypotensive, respiratory distress on admission.
• 20:12
  SPEAKER_02: He required intubation and pressers pretty quickly and was transferred to the MICU.
• 20:16
  SPEAKER_02: They did do blood cultures and bronchial alveolar lavage.
• 20:19
  SPEAKER_02: Vancomycin and triprocillantasobactum are started empirically.
• 20:22
  SPEAKER_02: Chest x-ray only shows some bilateral ground glass opacities and pulmonary edema, but no consolidation.
• 20:28
  SPEAKER_02: And on hospital day two, his COVID testing is positive and he begins to develop an acute kidney injury.
• 20:33
  SPEAKER_02: In this setting, we would recommend discontinuation of antibiotics if cultures are still negative after 48 to 72 hours.
• 20:40
  SPEAKER_02: Even if he remains intubated and on pressors and is still critically ill.
• 20:44
  SPEAKER_02: Continuing manchomyosin and piptezo could lead to worsening renal function and volume overloads, which can further complicate his clinical picture.
• 20:51
  SPEAKER_01: So now in contrast, let's talk about an example in which antibiotics are initiated in a hospitalized COVID-19 patient who's actively decompensating.
• 21:01
  SPEAKER_01: So we have a 70-year-old woman with coronary artery disease who was admitted to the medicine floor for supplemental O2 after a diagnosis of COVID-19.
• 21:10
  SPEAKER_01: She's in the hospital for a while, and on hospital day seven, her O2 requirement abruptly increases and she becomes hemodynamically unstable with increasing creatinine transaminitis and requires transfer to the MICU.
• 21:23
  SPEAKER_01: And phencomycin and peptazo are started on transfer.
• 21:27
  SPEAKER_01: So in this scenario, we know that patients with COVID-19 may decompensate several days into their hospital stay, but it's also important here to consider a hospital-acquired infection.
• 21:37
  SPEAKER_01: And as a result, it's reasonable to repeat blood cultures, to consider a BAL or respiratory cultures, repeat chest imaging, and look at lines and other potential sources of infection.
• 21:48
  SPEAKER_01: I think the key here is that it makes sense to start antibiotics in a patient with COVID-19 who decompensates abruptly.
• 21:55
  SPEAKER_01: But 48 to 72 hours later, after you've had some time to monitor your cultures and complete your investigation for a bacterial coinfection, it's time to stop antibiotics if you haven't diagnosed a bacterial infection.
• 22:08
  SPEAKER_04: Yes, so as we can see from the studies we've discussed in these case examples, stopping initiation may be challenging.
• 22:14
  SPEAKER_04: This is especially true if the patient isn't known to be COVID-positive on admission.
• 22:19
  SPEAKER_04: When we think about the COVID patients in whom antibiotics are initiated, monitoring these patients is important.
• 22:24
  SPEAKER_04: The available data support recommending discontinuation of antibiotics for patients who are culture negative, PCR negative, or patients without appropriate new symptoms to confirm the suspected bacterial infection.
• 22:36
  SPEAKER_04: We do need to keep an eye on any worsening symptom trajectory in hospitalized patients.
• 22:40
  SPEAKER_04: But when we think about the decision to order cultures or initiate antibiotics, it is important to consider their risk of healthcare associated infection as we would in any other hospitalized patient.
• 22:50
  SPEAKER_04: Evidence suggests that the same risk factors, such as device exposures, remain consistent in these COVID patients.
• 22:56
  SPEAKER_04: And ultimately, we need to worry less about stewardship in the severely ill patients who are actively dying.
• 23:00
  SPEAKER_04: We need to do what we can in these patients to help them.
• 23:03
  SPEAKER_04: And hopefully, as new treatment options continue to emerge, we'll have more effective options for treating the most severely ill COVID patients.
• 23:10
  SPEAKER_03: Thank you so much to our speakers for sharing y'all's perspectives and experiences and the perspective of the early literature from COVID.
• 23:18
  SPEAKER_03: And thank you to Shay for allowing us this chance to share this information with the listeners.
• 23:24
  SPEAKER_03: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 23:30
  SPEAKER_03: You will also find resources such as the recorded webinars, Healthcare Facility Outbreak Preparedness, and the SHAY COVID-19 town halls.
• 23:38
  SPEAKER_03: You can receive 50% off 2021 SHA membership using the coupon code WELCOME2021 during checkout.
• 23:44
  SPEAKER_03: That concludes this episode of the Rapid Response Podcast.
• 23:48
  SPEAKER_03: Thanks for tuning in.