Antibiotic Stewardship in Hospitals During Public Health Emergencies

Publication Date: September 14, 2022
Last Updated: October 5, 2022

Antibiotic Prescribing During a Pandemic or Epidemic

HCP should limit initiation of antibiotics – particularly broad-spectrum agents – for patients in acute care settings with high pre-test probability for a viral infection such as SARS-CoV-2 or influenza, even if there is lack of readily available and accurate diagnostics.

Diagnostic Testing for Patients Admitted to the Hospital During a Pandemic or Epidemic

HCP may perform inflammatory marker tests at baseline, particularly in critically ill patients, including C-reactive protein, lactate dehydrogenase, D-dimer, serum ferritin, and high-sensitivity troponin.

HCP should repeat laboratory testing only to the extent that it provides actionable clinical data.

HCP can monitor CRP if clinically indicated to inform respiratory viral treatments.
For COVID-19, CRP monitoring informed use of biologic agents such as tocilizumab or baricitinib.

HCP should not use inflammatory markers as the basis for initiation of antibiotics or antifungal agents because they may not be indicative of bacterial or fungal coinfection.
HCP should not use procalcitonin routinely to aid in the decision to initiate antibiotics.

HCP will need to monitor the relationship of inflammatory markers to infection in future infectious epidemics and pandemics.

HCP should not obtain bacterial cultures or respiratory multiplex PCR tests for patients who do not have indicators consistent with bacterial infection, particularly those with stable clinical status in a non-ICU setting.

When to Consider Antibotics for Patients During Respiratory Viral Pandemics and Epidemics

It is important for HCP to identify patients who require empiric antibiotic treatment, despite low rates of coinfection on admission for the COVID-19 and prior respiratory viral pandemics.

If treated at the time of hospital admission, HCP should prescribe antibiotics recommended in guidelines for CAP for patients presenting from the community with coinfection. Antibiotics for pathogens, such as Pseudomonas aeruginosa, seen more typically in healthcare-associated infection, are not recommended.

HCP may consider coinfection with other viruses, such as influenza. If influenza is diagnosed, addition of therapy, such oseltamivir, may be indicated.

HCP may consider antibiotics, including broad-spectrum coverage, for patients hospitalized for >48 hours who are at greater risk for HAIs and MDROs, when there are new clinical signs that are consistent with healthcare-associated bacterial or fungal infection.

Microbiologic and Radiologic Diagnostic Tests In Patients with Possible Bacterial Co-Infection On Antibiotics

Before initiating antibiotics, HCP should attempt to establish a microbiologic diagnosis.

HCP should limit respiratory multiplex PCR tests to ICU patients and patients who require broad-spectrum antimicrobial therapy.

HCP should restrict repeat microbiologic testing to changes in a patient’s clinical status.

HCP should perform a nasal MRSA swab for patients started on anti-MRSA treatment.

HCP should not perform routine testing for fungal infection in the absence of a clinical presentation that raises that concern.

HCP should review the necessity of antibiotics within 48–72 hours, as results from tests become available, and should de-escalate or discontinue antibiotic therapy based on those results and clinical response.
Procalcitonin results may aid the de-escalation or discontinuation of antibiotic treatments.

HCP should obtain chest radiographs to assess the extent of lung involvement, but daily repeat studies are not indicated. Use of CT of the chest should be reserved for circumstances in which results of the CT may result in a change in clinical management (eg, pulmonary embolus).

Role of the ASP in a Pandemic or Epidemic

ASPs should monitor emerging information and updates to national and international guidelines that are relevant to antibiotic prescribing, revise clinical recommendations relevant to antimicrobial use, and educate frontline HCP to support appropriate antibiotic stewardship.


Fig. 1. Model for ASP Activities in Public Health Emergencies

Recommendation Grading




Antibiotic Stewardship in Hospitals During Public Health Emergencies

Authoring Organization

Publication Month/Year

September 14, 2022

Last Updated Month/Year

September 12, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Document Objectives

This statement addresses the inappropriate antibiotic prescribing occurring during the coronavirus 2019 pandemic (COVID-19) that has exacerbated another urgent public health crisis: antibiotic resistance in bacterial and fungal pathogens. Reference Miranda, Silva, Capita, Alonso-Calleja, Igrejas and Poeta1–Reference Vidyarthi, Das and Chaudhry3 Ramifications of overprescribing have led to infections with multidrug-resistant organisms (MDROs) such as extended-spectrum β-lactamase–producing gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA). Reference Srinivasan4 These infections complicate patient treatment, prolong hospital stays, and lead to worse outcomes. Reference Son, Kim and Lee

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Management, Prevention

Diseases/Conditions (MeSH)

D000073602 - Antimicrobial Stewardship, D058873 - Pandemics, D011634 - Public Health


public health, Antibiotic Stewardship, pandemic

Source Citation

Barlam, T., Al Mohajer, M., Al-Tawfiq, J., Auguste, A., Cunha, C., Forrest, G., . . . Schaffzin, J. (2022). SHEA statement on antibiotic stewardship in hospitals during public health emergencies. Infection Control & Hospital Epidemiology, 1-12. doi:10.1017/ice.2022.194


Number of Source Documents
Literature Search Start Date
December 1, 2019
Literature Search End Date
August 17, 2021