Response to: “the impact of age, disease severity, and vaccination status on antibiotic use in hospitalized patients with COVID-19”

KEYWORDS:

• antimicrobial stewardship
• COVID-19
• antibiotics
• co-infections
• super-infections
• antimicrobial resistance

1.

We thank the authors of the letter ‘The impact of age, disease severity, and vaccination status on antibiotic use in hospitalized patients with COVID-19’ for their comments on our perspective article ‘Use of antibiotics in hospitalized patients with COVID-19: evolving concepts in a highly dynamic antimicrobial stewardship scenario’ [1,2].

In a pre-print manuscript, they reported on the estimated, dynamic changes in the prevalence of antibiotic use in hospitalized patients with COVID-19 in Hong Kong, with a decreasing trend over the first four waves and then a novel peak to 65% during the first Omicron wave (more in detail, from January to May 2022) [1,3]. Subsequently, up to September 2022, the estimated prevalence of antibiotic use in hospitalized patients with COVID-19 in Hong Kong fell again, to 43% [3]. As noticed by the authors, an important discrepancy still remained between prevalence of antibiotic use (43%) and confirmed bacterial co-infections (7%), in line with what highlighted in a recent cluster-randomized non-inferiority trial and with the summary effects in a recent meta-analysis [4–6]. The more interesting finding reported by the authors, in our opinion, is that previous receipt of COVID-19 vaccine was associated with reduced antibiotic prescriptions in hospitalized patients with COVID-19 (four doses vs. no vaccination as reference, odds ratio for inpatient antibiotic prescription 0.52, with 95% confidence interval from 0.44 to 0.62) [1,3]. Although the authors describe this association as strong, we feel some caution remains mandatory, since it should be verified in adjusted analyses and after peer-review of the released pre-print manuscript. However, this preliminary result is certainly of interest. Consequently, we encourage the authors to provide more details on their analysis in a future peer-reviewed publication. This would also be relevant for fully interpreting subgroup analyses, aiming to provide a more comprehensive understanding of antibiotic prescribing patterns in hospitalized patients with COVID-19 according to different demographic and clinical characteristics.

Finally, we agree high between-study heterogeneity in meta-analyses of observational studies on this and other similar topics is to be expected, and probably, eventually unavoidable. Nonetheless, when visually comparing effect sizes in single studies, only a few had prevalences of antibiotic prescribing < 50% [4]. In our opinion, this consistency supports the presence of a true baseline necessity to reduce antibiotic prescribing in the population of interest. For this reason, we agree actionable evidence-based recommendations could be essential to further curtail inappropriate antibiotic prescribing in hospitalized patients with COVID-19.

Declaration of interest

Outside the submitted work, M Bassetti has received funding for scientific advisory boards, travel, and speaker honoraria from Angelini, Astellas, BioMérieux, Cidara, Gilead, Menarini, MSD, Pfizer, Shionogi, Tetraphase, Nabriva. Outside the submitted work, D R Giacobbe reports investigator-initiated grants from Pfizer, Shionogi, BioMérieux, and Gilead Italia, and speaker/advisor fees from Pfizer, Menarini, and Tillotts Pharma. The other authors have no conflicts of interests to disclose.The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This paper was not funded.