German Study Finds That Antibiotic Use In Hospitalized COVID-19 Patients Offers No Beneficial Clinical Outcomes

COVID-19 News: The COVID-19 pandemic has brought forth numerous challenges, among which is the appropriate use of antibiotics in hospitalized patients. Recent research from Germany sheds light on this issue, revealing that antibiotic treatment in adults with moderate COVID-19 may not yield beneficial clinical outcomes and could potentially lead to deterioration. This COVID-19 News report delves into the implications of this study, emphasizing the need for judicious antibiotic use and improved stewardship interventions in the context of viral pandemics like COVID-19.


German Study Finds That Antibiotic Use In Hospitalized COVID-19
Patients Offers No Beneficial Clinical Outcomes

The Study's Background and Objectives
The study findings, to be presented at the coming ESCMID Global Congress in Barcelona, Spain (https://www.escmid.org/congress-events/escmid-global/ ) focused on analyzing data from the German National Pandemic Cohort Network (NAPKON) comprising 1,317 hospitalized adults with confirmed SARS-CoV-2 infection between March 2020 and May 2023. The primary objective was to investigate the impact of antibiotic use on the clinical progression of COVID-19 patients, particularly those with moderate disease severity.
 
Rationale Behind Antibiotic Use in COVID-19 Patients
Dr Anette Friedrichs, the lead author of the study, highlighted the rationale for antibiotic use in COVID-19 patients. Antibiotics are typically prescribed when bacterial co- or superinfections are suspected or confirmed, especially in cases where a second infection develops on top of COVID-19. However, distinguishing between bacterial superinfections and advanced stages of COVID-19 can be challenging, leading to the overuse of antibiotics in hospitalized patients diagnosed with COVID-19.
 
Data Analysis and Patient Characteristics
The study cohort consisted of predominantly middle-aged individuals, with a significant proportion being male. Patients were categorized based on disease severity using the WHO Clinical Progression Scale, with a focus on those classified as having moderate disease (WHO score 4-5). Of these patients, 41% received antibiotic treatment during their hospital stay, primarily targeting respiratory infections. Notably, older age, male gender, greater disease severity, higher comorbidity burden, and lack of prior COVID-19 vaccination were associated with increased likelihood of antibiotic treatment.
 
Impact of Antibiotic Therapy on Clinical Progression
The researchers assessed patients' clinical status after 14 days using the WHO Clinical Progression Scale, accounting for various COVID-19 risk factors. The analysis revealed that patients treated with antibiotics had a five-fold greater risk of clinical deterioration compared to those not receiving antibiotics. Additionally, patients aged 65 or older faced a three-fold increased likelihood of COVID-19 deterioration, i ndicating a potential interaction between age, antibiotic use, and disease progression.
 
Details of Findings
Utilizing the WHO Clinical Progression Scale, the study team identified 1,149 patients who were classified as having moderate disease (WHO score 4-5), of whom 467 (41%) were treated with antibiotics commonly used for respiratory infections such as ß-Lactam-antibiotics, macrolides, or moxifloxacin during their hospital stay. Some were also given azithromycin or neomycin.
 
Another 168 patients were classed as having severe disease (WHO score 6-9), of whom 118 (70%) also received antibiotic treatment. The data on these patients are still being analyzed.
 
Detailed microbiological investigations of patients with moderate disease found only 11 patients with a superinfection with a bacterium that can also cause pneumonia - eight patients treated with antibiotics and three who did not receive antibiotics. The study team noted that the low number of patients with documented respiratory bacterial superinfection might be due to missing microbiological diagnostics or missing documentation of results. Other bacterial infections suggestive for antibiotic therapy were not included in the analysis.
 
The study team then analyzed the influence of antibiotic therapy on patients' clinical status after 14 days measured using the WHO Clinical Progression Scale, which reflects a patient's trajectory and resource use over the course of clinical illness. The score indicates disease severity incorporating hospital admission, oxygen requirement, ventilator support, admission to intensive care unit and organ replacement therapy. The score was calculated for each patient at the initial clinician's consultation, and again 14 days later to see whether the score had improved, remained stable, or worsened.
 
Upon controlling for COVID-19 risk factors including age, sex, and underlying medical conditions, the analyses found that clinical improvement in patients with moderate disease was significantly better for younger, female, and vaccinated patients.
 
Significantly, patients given antibiotics had five times greater risk of clinical deterioration after 14 days compared to those not treated with antibiotics. Similarly, being aged 65 or older trebled the likelihood of COVID-19 deterioration compared to those aged 18-50 years.
 
Dr Friedrichs commented, "This increased risk is possibly due to unknown additional factors that result in worse outcomes and are associated with antibiotic treatment. One potential factor that was only occasionally documented is a bacterial superinfection, as well as other bacterial infections. Importantly, however, clinical deterioration can also develop from the side effects of unnecessarily prescribed antibiotics."

Thailand Medical News would like to add that while research in animal studies showed that certain antibiotics had favourable results, it should be noted that in infected COVID-19 individuals, the virus is able to cause damages to the heart and kidneys and certain antibiotics are known to cause QT prolongation and arrhythmias and also cause kidney damage, thus aggravating conditions in those already infected with SARS-CoV-2.
 
Understanding the Risk Factors and Implications
Dr Friedrichs emphasized that while bacterial superinfections or other bacterial infections could contribute to clinical deterioration, the adverse effects of unnecessary antibiotics cannot be overlooked. The study's findings underscore the need for cautious antibiotic prescribing practices, especially during viral pandemics. Furthermore, the lack of documented bacterial infections in a significant proportion of patients receiving antibiotics raises concerns about indiscriminate antibiotic use.
 
Lessons Learned and Recommendations
The COVID-19 pandemic serves as a critical lesson for future viral outbreaks, highlighting the importance of rational antibiotic use and strengthened stewardship programs. Dr Friedrichs advocates for limiting antibiotics to patients with suspected bacterial coinfections and conducting appropriate microbiological diagnostics before initiating treatment. Moreover, discontinuing antibiotics when bacterial coinfections are unlikely is essential to mitigate the risk of antibiotic resistance and adverse outcomes.

Study Limitations and Generalizability
Despite its insights, the study has limitations inherent to its observational nature and single-country focus. The findings may not fully capture all contributory factors influencing clinical outcomes in COVID-19 patients globally. Therefore, caution is warranted when extrapolating these results to diverse populations and healthcare settings.
 
Conclusion: Navigating Antibiotic Use in COVID-19 Care
In conclusion, the German study's findings shed light on the complexities surrounding antibiotic use in hospitalized COVID-19 patients. While antibiotics play a crucial role in managing bacterial infections, their indiscriminate use can exacerbate antimicrobial resistance and lead to adverse clinical outcomes. Moving forward, a balanced approach that integrates evidence-based antibiotic prescribing, stringent diagnostic criteria, and robust stewardship initiatives is imperative to optimize patient care during viral pandemics.
 
For the latest COVID-19 News, keep on logging to Thailand Medical News.