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.
6731

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.
6731
HCP should repeat laboratory testing only to the extent that it provides actionable clinical data.
6731
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.
6731
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.
6731
HCP will need to monitor the relationship of inflammatory markers to infection in future infectious epidemics and pandemics.
6731
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.
6731

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.
6731
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.
6731
HCP may consider coinfection with other viruses, such as influenza. If influenza is diagnosed, addition of therapy, such oseltamivir, may be indicated.
6731
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.
6731

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.
6731
HCP should limit respiratory multiplex PCR tests to ICU patients and patients who require broad-spectrum antimicrobial therapy.
6731
HCP should restrict repeat microbiologic testing to changes in a patient’s clinical status.
6731
HCP should perform a nasal MRSA swab for patients started on anti-MRSA treatment.
6731
HCP should not perform routine testing for fungal infection in the absence of a clinical presentation that raises that concern.
6731
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.
6731
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).
6731

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.
6731

Figures

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

Recommendation Grading

Overview

Title

Antibiotic Stewardship in Hospitals During Public Health Emergencies

Authoring Organization

Society for Healthcare Epidemiology of America

Publication Month/Year

September 14, 2022

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

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

Scope

Management, Prevention

Diseases/Conditions (MeSH)

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

Keywords

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

Methodology

Number of Source Documents
106
Literature Search Start Date
December 1, 2019
Literature Search End Date
August 17, 2021