key: cord-325186-nq6ay4eo
authors: Sieswerda, Elske; De Boer, Mark G.J.; Bonten, Marc M.J.; Boersma, Wim G.; Jonkers, René E.; Aleva, Roel M.; Kullberg, Bart-Jan; Schouten, Jeroen A.; van de Garde, Ewoudt M.W.; Verheij, Theo J.; van der Eerden, Menno M.; Prins, Jan M.; Wiersinga, W. Joost
title: Recommendations for antibacterial therapy in adults with COVID-19 – An evidence based guideline
date: 2020-10-01
journal: Clin Microbiol Infect
DOI: 10.1016/j.cmi.2020.09.041
sha: 
doc_id: 325186
cord_uid: nq6ay4eo

SCOPE: The Dutch Working Party on Antibiotic Policy constituted a multidisciplinary expert committee to provide evidence-based recommendation for the use of antibacterial therapy in hospitalized adults with a respiratory infection and suspected or proven 2019 Coronavirus disease (COVID-19). METHODS: We performed a literature search to answer four key questions. The committee graded the evidence and developed recommendations by using Grading of Recommendations Assessment, Development, and Evaluation methodology. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: We assessed evidence on the risk of bacterial infections in hospitalized COVID-19 patients, the associated bacterial pathogens, how to diagnose bacterial infections and how to treat bacterial infections. Bacterial co-infection upon admission was reported in 3.5% of COVID-19 patients, while bacterial secondary infections during hospitalization occurred up to 15%. No or very low quality evidence was found to answer the other key clinical questions. Although the evidence base on bacterial infections in COVID-19 is currently limited, available evidence supports restrictive antibiotic use from an antibiotic stewardship perspective, especially upon admission. To support restrictive antibiotic use, maximum efforts should be undertaken to obtain sputum and blood culture samples as well as pneumococcal urinary antigen testing. We suggest to stop antibiotics in patients who started antibiotic treatment upon admission when representative cultures as well as urinary antigen tests show no signs of involvement of bacterial pathogens after 48 hours. For patients with secondary bacterial respiratory infection we recommend to follow other guideline recommendations on antibacterial treatment for patients with hospital-acquired and ventilator-associated pneumonia. An antibiotic treatment duration of five days in patients with COVID-19 and suspected bacterial respiratory infection is recommended upon improvement of signs, symptoms and inflammatory markers. Larger, prospective studies about the epidemiology of bacterial infections in COVID-19 are urgently needed to confirm our conclusions and ultimately prevent unnecessary antibiotic use during the COVID-19 pandemic.

infection to life-threatening pneumonia. Severe disease is frequently associated with high 66 inflammation marker levels. It is therefore challenging to define if a patient fulfilling criteria 67 for CAP who is positive for SARS-CoV-2 has a bacterial co-infection upon admission. During 68 hospitalization it may be difficult to distinguish between severe COVID-19 and bacterial 69 secondary infections. 70 In several reports the majority of hospitalized patients with COVID-19 were treated with 71 broad-spectrum antibiotics with unknown efficacy [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . As COVID-19 patients frequently 72 need prolonged hospitalization and respiratory support, unnecessary antibiotics upon 73 hospitalization may increase the individual risk of subsequent hospital-acquired pneumonia 74 (HAP) and other adverse events [12, 13] . On a population level, universal antibiotic 75 prescriptions for all or the vast majority of hospitalized COVID-19 patients can lead to a 76 steep increase in antibiotic use during a pandemic and as a result, a potential increase in 77 antimicrobial resistance rates [14] . 78 The Dutch Working Party on Antibiotic Policy (SWAB) coordinates activities in the 79 Netherlands with the aim to optimize antibiotic use, to contain the development of and Acinetobacter baumannii were isolated from respiratory material [19] . In one patient in 178 the Netherlands, Pseudomonas aeruginosa was cultured from blood, but it was not CoV-2 and Other Respiratory Pathogens, Jama (2020). J o u r n a l P r e -p r o o f 

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