Maintaining rational prescribing practices during a crisis

DrDananja

By

Dr Dhananja Namalie
Consultant Microbiologist
CNTH

In the context of the current COVID 19 pandemic, a high number of patients are getting affected with the SARS CoV 2 virus, and many cases can be tackled by one’s immune system as it is the case in many viral illnesses. Vaccination also gives additional protection against severe illness. For mild and most moderate cases, rest, adequate fluid intake, healthy diet is all what is needed. So far, no effective antiviral agent has been approved for use and steroids are only indicated in severe cases (1,6).

Antibiotics are effective only when there is evidence of secondary infection which generally happens few days after the initial infection. This can be either co-infection or infection after recovering from the initial infection. Secondary infections occur primarily due to mechanical damage to respiratory tract and lungs and immune dysfunction caused by the SARS CoV 2 infection. Features of secondary bacterial infection are presence of persistent fever, high c reactive protein levels, production of purulent sputum, presence of neutrophil leukocytosis and worsening of radiological features of pneumonia. Common organisms causing secondary bacterial infections following respiratory viral infections are Streptococcus pneumoniae, Staphylococcus aureus, Haemophillus influenzae, Moraxella caterahalis and uncommonly gram negative enterobacterales such as Escherichia coli and Klebsiella pneumoniae. Pseudomonas aureginosa and other Gram negative non fermenters are uncommon unless there is preexisting chronic lung disease or prolonged hospital stay. (3) Fungal infections become common after prolonged use of steroids or if the patient has underlying immunosuppressive conditions. Mycobacterium tuberculosis also has been reported (4). In published literature, varying rates of secondary infections were reported ranging from 5 to 15% and fatalities were common among patients with secondary infections. (2,3,5)

For patients having mild and moderate disease who can be managed in outpatient setting, oral agents such as 1st and 2nd generation cephalosporins (cephalexin, cefuroxime) or a macrolide such as clarythromycin in cases of betalactam allergy and when co-infection with atypical organisms are suspected are indicated. Antimicrobials should not be prescribed for preventing secondary bacterial infections in COVID 19.

For moderate and severe cases requiring hospital admission who have evidence of secondary infection could be treated with oral cefuroxime or coamoxylav. Intravenous antibiotics and 3rd generation cephalosporins with or without anti-pseudomonal properties   are indicated if they are having signs of severe sepsis. Anti psedomonal betalactam and betalactamase inhibitor combinations and carbapenems should be reserved for patients who are not responding to above agents or when patients have other underlying conditions such as uncontrolled diabetes, chronic liver cell disease, chronic kidney disease and malignancies which make them immune-compromised or when colonization with multi-drug resistant organisms is known or suspected. Specimens for microbiological investigations should be taken before starting antimicrobials whenever possible and antibiotics should be re-assessed when culture results are available. Empiric treatment for nosocomial secondary infections should be commenced according to national antibiotic guideline or institutional guides depending on the antibiogram of the facility that the patient is housed. It is advisable to seek the expert opinion of a clinical microbiologist in such instances.

It has become a common practice among general practitioners to prescribe a list of unnecessary medications for mild to moderate cases of COVID 19. This cocktail includes antihistamines, steroids, antimicrobials which includes antibiotics and anti-parasitic drugs. There had been instances of sharing these prescriptions given to one patient among others through various social media platforms and polypharmacy is not a rarity in our country. All these drugs cause more evil than good for the patients who reach medical professionals trusting them.

Antimicrobial resistance (AMR) is one of major challenges that the field of medicine is facing today. It has been predicted that millions of lives will be claimed by the super bugs pushing the world to a post antibiotic era in future which will be similar to the pre antibiotic era. Therefore, antibiotic use should be done extremely cautiously during the peaks of current pandemic without pushing the world to another pandemic caused by superbugs. Having rational prescribing practices and adherence to evidence-based guidelines with self-stewardships is important to save antimicrobials “the rapidly waning finite resource” for the future generations.

References

  1. WHO living guideline on therapeutics and COVID-19 ,24September2021, (https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-therapeutics-2021.3)
  2. Noa Shafran N., Shafran I., Ben-Zvi H., Sofer S.,Sheena L., Krause I.,Shlomai A.,Goldberg, Ella E. . Secondary bacterial infection in COVID-19 patients is a stronger predictor for death compared to influenza patients Scientific Reports. 2021; 11: 12703.
  3. Adelman M. W., Divya R. Bhamidipati , Alfonso C. Hernandez-Romieu , Ahmed Babiker , Michael H. Woodworth , Robichaux C. David J. Murphy, Sara C. Auld, Colleen S. Kraft . Jesse T. Jacob Secondary Bacterial Pneumonias and Bloodstream Infections in Patients Hospitalized with COVID-19, Annals of the American Thoracic Society 2021 ;18(9):1584-1587.
  4. Fattorini L., Creti R., Palma C., Pantosti A., Bacterial coinfections in COVID-19: an underestimated adversary, Annali dell'Istituto Superiore di Sanità 2020;56 (3): 359-364
  5. Hughes S, Troise O, Donaldson H, Mughal N, Moore LSP. Bacterial and fungal coinfection among hospitalized patients with COVID-19: a retrospective cohort study in a UK secondary-care setting Clinical Microbiology and Infection. 2020;26(10):1395-1399.
  6. COVID-19 rapid guideline: Managing COVID-19 NICE 6 October 2021 (https://www.guidelines.co.uk/infection/nice-covid-19-management/455939)

Author: Piume madushani