Empiric Antibacterial Therapy and Community-onset Bacterial Co-infection in Patients Hospitalized with COVID-19: A Multi-Hospital Cohort Study

Vaughn, Valerie M; Gandhi, Tejal; Petty, Lindsay A; Patel, Payal K; Prescott, Hallie C; Malani, Anurag N; Ratz, David; McLaughlin, Elizabeth; Chopra, Vineet; Flanders, Scott A

BACKGROUND: Antibacterials may be initiated out of concern for bacterial co-infection in patients with COVID-19. We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial co-infections in hospitalized patients with COVID-19. METHODS: Randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020-6/18/2020. Data were collected on early (prescribed within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial co-infections (positive culture or diagnostic test within 3 days). Poisson generalized estimating equation models were used to assess predictors of empiric antibacterial use. RESULTS: Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27%-84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years), had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m (2)), had more severe illness (e.g., severe sepsis, ARR: 1.16 [1.07-1.27]), had a lobar infiltrate (ARR: 1.21 [1.04-1.42]), or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs. in April [85.2%, 628/737], P<.001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs. March) decreased. CONCLUSION: The prevalence of confirmed community-onset bacterial co-infections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.