key: cord-0966424-yrs3ioj2
authors: Colaneri, Marta; Valsecchi, Pietro; Vecchia, Marco; Filippo, Alessandro Di; Zuccaro, Valentina; Seminari, Elena; Sacchi, Paolo; Maiocchi, Laura; Fabbiani, Massimiliano; Ricciardi, Alessandra; Muzzi, Alba; Bruno, Raffaele
title: What prompts clinicians to start antibiotic treatment in COVID-19 patients? An Italian web-survey helps us understand where the doubts lie
date: 2021-06-09
journal: J Glob Antimicrob Resist
DOI: 10.1016/j.jgar.2021.05.014
sha: efbdc67ae7d99c9779bf05f03c459931abb4c699
doc_id: 966424
cord_uid: yrs3ioj2

nan

The appropriateness of antimicrobials prescribing during COVID 19 pandemics has become a significant issue because antimicrobial stewardship rules have been frequently disregarded [1] .

Although the current medical literature is consistent in reporting a low incidence of bacterial coinfections in COVID-19 hospitalized patients and WHO's interim guidance does not recommend antibiotic therapy or prophylaxis, the real-life usage of broad-spectrum antimicrobials has undoubtedly been excessive [2, 3, 4] . What still remains unclear is the propensity of physicians in deciding whether to prescribe an antimicrobial treatment in COVID-19 patients.

To investigate the reasons for antibiotics prescribing, we have designed an online survey which we subsequently administered to Italian physicians experienced in the management of COVID-19.

The survey has been developed by the ID team of our Hospital, Policlinico San Matteo of Pavia, Northern Italy.

In December 2020, the survey has been sent by providing an email link (https://docs.google.com/forms/)to the directors of several specialist (internal medicine, emergency room, chest medicine and infectious diseases) of referral Hospitals in Northern, Central and Southern

Italy. The answers have been collected in January 2021.

The survey is composed of demographic, clinical, radiologic and microbiologic variables, and its aim is to identify those more frequently marked as relevant in deciding whether or not to start an antibiotic treatment. The exact weight recognized for each one of these was assigned on a scale from 1 to 5, whereby 1 is "not relevant" and 5 is "extremely relevant". A total of 51 questions have been administered To overcome the relevant bias related to physicians' previous work-experiences, we compared the propensity of ID specialists and non-ID specialists and, among ID specialists, the experienced (>10 years of work experience) and non-experienced (< 10 years of work experience). Ttests were conducted and the Bonferroni correction (factor, procedure?) was applied to adjust the experiment-wise error rate of multiple T tests.

Analyses and graphical illustrations have been produced with the freeware software R version 3.5.1 (R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria).

In total, 680 phycisicians received our survey and 414 (60.8%) have answered. The mean age being 45 years (SD 12.5) with an almost equal percentage of males and females. Specialists in internal medicine were the majority (35,9%), followed by specialists in infectious diseases (32,6%), emergency room (21,5%) and chest medicine (9,9%). More than half (56,8%) had been working as specialists for more than 10 years.

Results are represented in Figure 1 Furthermore, with regards to the difference in starting antibiotics treatment in -experienced and not experienced ID specialists' groups, very little difference was observed, with older physicians apparently assigning a higher score to males, obese and diabetic patients

Our data show that antibiotics prescribing in COVID 19 patients is driven by presence of such comorbidities (HSCT, presence of bronchiectasis), a definite microbial isolation, PCTI levels, chest xray and ultrasound pattern, in-hospital disease worsening, and Intensive Care Unit (ICU) hospitalization and orotracheal intubation (OTI) [5] .

We found that infectious diseases (ID) specialists tend to spare the antibiotics on most occasions, being well aware of emergence of resistance, .and to consider MDR germs colonization and risk factors for MDR germs infection as not crucial in starting the antimicrobial treatment, with an expectantly even lower average value for the colonization.

We have further explored whether the weight attributed to each variable might vary depending on the work experience and we found that young ID specialists tend do not prescribe antibiotics in patients such as males, diabetic and obese, perhaps because seniors' have experienced a poorer outcome of this subjects.

The lack of prescribing indications likely encourage each specialist to rely on his own habits and, as a consequence, the antimicrobial stewardship principles are at risk to be disregarded. Thus

Antimicrobial Stewardship Programs should quickly be implemented and multidisciplinary evaluation with experts in antimicrobial treatment may improve antibiotic use use. Funding: none.

COVID-19: don't neglect antimicrobial stewardship principles! Clin Microbiol Infect

Co-infections in people with COVID-19: a systematic review and meta-analysis

World Health Organization. Clinical management of COVID-19 interim guidance

Bacterial and fungal coinfections in COVID-19 patients hospitalized during the New York City pandemic surge

Predictors of hospital-acquired bacterial and fungal superinfections in COVID-19: a prospective observational study

Percentage of agreement on the weight (from 1 to 5) assigned to the considered variables, subdivided among demographic, clinical, radiological microbiological and laboratory by the overall cohort of physicians (n=414).The principal variables are in bold

We are grateful to all the physicians who voluntarily completed the questionnaire, thereby actively supporting this study.

The authors declare no conflict of interest.Ethical approval: Not required