key: cord-0684803-tgh1jhcv
authors: Odille, Geoffrey; Girard, Noémie; Sanchez, Stéphane; Lelarge, Sarah; Mignot, Alexandre; Putot, Sophie; Larosa, Fabrice; Vovelle, Jérémie; Nuss, Valentine; Da Silva, Sofia; Barben, Jérémy; Manckoundia, Patrick; Putot, Alain
title: Should We Prescribe Antibiotics in Older Patients Presenting COVID-19 Pneumonia?
date: 2020-12-04
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.11.034
sha: 9badb2fa31c0ad0143bfaa12b77341da03756c43
doc_id: 684803
cord_uid: tgh1jhcv

nan

Should We Prescribe Antibiotics in Older Patients Presenting COVID-19 Pneumonia?

To the Editor:

The COVID-19 pandemic is responsible for a particularly high level of morbidity in the older population. 1 Most deaths are the result of severe viral pneumonia, for which therapeutic management is still a matter of debate. Corticosteroids are to date the only therapeutic class that has proven benefit in terms of mortality in hypoxemic SARS-CoV-2 pneumonia, 2 whereas the benefit of tocilizumab remains unclear. 3 However, such therapeutics are associated with increased risk of bacterial infection, especially among older individuals. Moreover, the distinction between bacterial and viral pneumonia is particularly difficult, and coinfections have been highlighted, although in limited proportions. 4e6 There is currently no distinctive tool to conclusively distinguish SARS-CoV-2 pneumonia from viral-bacterial coinfections, and atypical symptoms are particularly frequent in older patients. 7 Recent guidelines suggest a restrictive use of antibacterial drugs in patients with COVID-19. 6, 8 However, the level of evidence for such recommendations is very low, and antibiotics are widely prescribed in practice, 4,5 especially in older patients. 9 To our knowledge, whether systemic antibiotic therapy should be prescribed in acute pneumonia patients testing positive for COVID-19 has not been evaluated yet in a geriatric setting. In a multicenter retrospective cohort study of older patients with a SARS-CoV-2 pneumonia, we sought to assess whether the use of antibiotics was associated with lower mortality.

We included 124 consecutive patients aged 75 years hospitalized from March 1 to May 1, 2020, in 4 hospitals of one of the French regions most affected by the first wave of COVID-19. Patients had radiology-proven pneumonia and tested positive for SARS-CoV-2 (Real-Time Polymerase Chain Reaction Novodiag; Movidiag, Espoo, Finland). We compared mortality 1 month after admission between patients with and without antibiotic treatment (Supplementary Material).

Pneumonia was defined according to the American guidelines, in the acute presence of (1) 2 or more of the following signs: new cough, sputum production, dyspnea, pleuritic pain, abnormal temperature (<35.6 C or >37.8 C), or altered breathing sounds on auscultation and (2) a new infiltrate on chest imaging. 10 Of the 124 patients with pneumonia, 102 (82%) received antibiotics and 22 received none. The 2 groups were similar in terms of sex (male 52% vs 48%, P ¼ .9), age [median age (interquartile range): 85 (81-89) vs 86 (83-90), P ¼ .4] and comorbidities [median Charlson Comorbidity Index: 2 (1-4) vs 3 (2-4), P ¼ .2). However, patients with antibiotics had more severe presentation (severe or critical pneumonia according to WHO criteria 10 : 49% vs 23%, P ¼ .02). Alveolar condensation was identified on the CT scan in 38% and 27%, respectively (P ¼.3). The antibiotic regimens included third-generation cephalosporins (3GC) (75 patients), macrolides (50 patients), penicillin þ beta-lactamase inhibitor (40 patients), and fluoroquinolones (9 patients). Antibiotic associations were frequent, especially 3GC with macrolides (45 patients).

As shown in Figure 1 , mortality rates did not significantly differ between the 2 groups at 1 month (36% of death in both groups; P > .99). After adjustment on WHO severity classes, 8 Charlson Comorbidity Index, age, sex, and mortality did not significantly differ in the 2 groups [adjusted hazard ratio (95% confidence interval) ¼ 0.88 (0.40-1.92), P ¼ .7]. Median duration of hospital stay did not significantly differ between the 2 groups [11 (7-16) vs 10 (7-19) days, P ¼ .8]. Bacteremia during hospitalization was rare in both groups (5% vs 4%, P ¼ .9). One case of Clostridioides difficile colitis was diagnosed in the antibiotics group.

In this observational study in older comorbid inpatients presenting severe forms of COVID-19, 1-month mortality was very high (nearly a third of patients) and did not appear to widely differ under antibiotic treatment. If confirmed, these preliminary results from a relatively small cohort of older inpatients with severe SARS-CoV-2 pneumonia suggest that the use of antimicrobial drugs should be restricted.

The effect of age on mortality in patients with COVID-19: A meta-analysis with 611,583 subjects

Dexamethasone in hospitalized patients with COVID-19dPreliminary report

Efficacy of tocilizumab in patients hospitalized with COVID-19

Few bacterial co-infections but frequent empiric antibiotic use in the early phase of hospitalized patients with COVID-19: Results from a multicentre retrospective cohort study in the Netherlands

Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing

Recommendations for antibacterial therapy in adults with COVID-19 -an evidence based guideline

National French survey of COVID-19 symptoms in people aged 70 and over

Clinical management of COVID-19

Inpatient antibiotic utilization in the Veterans Administration during the COVID-19 pandemic

Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the

The authors thank Suzanne Rankin for the English review of the manuscript.

All patients aged 75 and older hospitalized for SARS-CoV-2 acute pneumonia in COVID-19 geriatric units of 4 hospitals of France, between March 1 and May 1, 2020, were prospectively included. In addition to a nasopharyngeal sample testing positive for SARS-CoV-2 (Real-Time Polymerase Chain Reaction Novodiag; Movidiag, Espoo, Finland), the following criteria for acute pneumonia, defined by the Current American guidelines, were required: (1) 2 or more of the following signs: new cough, sputum production, dyspnea, pleuritic pain, abnormal temperature (<35.6 C or >37.8 C), altered breathing sounds on auscultation; and (2) a new infiltrate on chest imaging. Patients with ventilatorassociated pneumonia were not included. This observational study was conducted in accordance with the Declaration of Helsinki and national standards. The Ethics Committee of our Hospital was consulted and approved the study.

For each subject, we recorded demographic, clinical, and laboratory data including age, gender, residential status, underlying diseases, Charlson Comorbidity Index (CCI), Pneumonia Severity Index (PSI), CURB-65 score, WHO severity class, and clinical presentation at admission. Follow-up at 1 month was systematically obtained through a phone call to the patient, or if unsuccessful, to his or her relatives. There was no loss to follow-up.

We compared patients receiving any antibiotic during at least 48 hours during hospitalization to patients receiving no or less than 48 hours of antibiotic therapy. Continuous variables were expressed as medians and interquartile ranges, and categorical variables as numbers and percentages. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using the chi-square test and Fisher test when appropriate.Logistic regression analysis was performed to assess the association of antibiotic treatment on mortality after adjustment on prespecified prognostic factors (age, sex, CCI, WHO severity classes). Kaplan-Meier curves and the log rank test were performed to compare 1-month mortality of patients with and without antibiotics. Statistical analyses were performed using SPSS 21.0 software (IBM Corp, Armonk, NY). All statistical tests were 2-tailed. Statistical significance was defined as P <.05.