COVID-19 Yoğun Bakım Ünitesinde Antibiyotik Kullanımı
Özet
COVID-19 yoğun bakım ünitelerinde ampirik antibiyotik kullanımı, bakteriyel koenfeksiyon sıklığının %3.5 gibi oldukça düşük düzeylerde seyretmesi nedeniyle genel olarak önerilmemekte, fakat gerçekte hastaların yaklaşık %72 ile %90 gibi çok yüksek bir oranına gereksiz yere antibiyotik reçete edilmektedir. Bu aşırı ve uygunsuz antimikrobiyal kullanımı küresel ölçekte ciddi bir antibiyotik direnci tehdidi oluştururken, hastalarda QT uzamasına bağlı ani kardiyak arrest ve antibiyotik ilişkili ishal gibi istenmeyen toksik etkilere yol açabilmektedir. Bakteriyel koenfeksiyon riski; ileri yaş, diyabet, kronik böbrek ve kalp hastalıkları gibi komorbiditeleri olanların yanı sıra immünsüpresif tedavi gören kritik hastalarda ve mekanik ventilasyon desteği alanlarda belirgin şekilde artış göstermektedir. Tanıda lökositoz, nötrofili veya prokalsitonin gibi inflamatuar parametreler tek başına yeterli duyarlılık ve özgüllüğe sahip olmadığından, ampirik tedaviye başlama kararının klinik seyir, radyolojik bulgular ve mikrobiyolojik kültür testlerinin bir kombinasyonuyla verilmesi gerekmektedir. Sonuç olarak, yoğun bakım ünitelerinde dirençli sekonder enfeksiyonların ve gereksiz antibiyotik sarfiyatının önlenmesi amacıyla multidisipliner antimikrobiyal yönetim rehberlerinin oluşturulması, ampirik tedavilerin yerel epidemiyolojik verilere göre planlanması ve uygun hastalarda erken oral tedaviye geçilerek deeskalasyon stratejilerinin titizlikle uygulanması büyük önem taşımaktadır.
The use of empirical antibiotics in COVID-19 intensive care units is generally not recommended due to the very low rate of bacterial co-infection, which is around 3.5%, yet in reality, a high rate of approximately 72% to 90% of hospitalized patients receive unnecessary antibiotic prescriptions. This excessive and inappropriate antimicrobial use poses a severe threat of global antimicrobial resistance and can lead to adverse toxic effects in patients, such as sudden cardiac arrest secondary to QT prolongation and antibiotic-associated diarrhea. The risk of bacterial co-infection increases significantly in patients with comorbidities like advanced age, diabetes, chronic kidney, and heart diseases, as well as in critically ill patients receiving immunosuppressive therapy and those on mechanical ventilation. Since inflammatory parameters such as leukocytosis, neutrophilia, or procalcitonin lack sufficient sensitivity and specificity on their own for diagnosis, the decision to initiate empirical therapy must be guided by a combination of clinical course, radiological findings, and microbiological cultures. Consequently, to prevent resistant secondary infections and unnecessary antibiotic consumption in intensive care units, it is of paramount importance to establish multidisciplinary antimicrobial stewardship guidelines, plan empirical treatments based on local epidemiological data, and rigorously implement de-escalation strategies by transitioning eligible patients to early oral therapy.
Referanslar
Dünya Sağlık Örgütü 2019. (01/02/2022 tarihinde https://covid19.who.int/ adresinden ulaşılmıştır).
Martín-Loeches I, Sanchez-Corral A,, Diaz E, et al. Community-acquired respiratory coinfection in critically ill patients with pandemic 2009 influenza A (H1N1) virus. Chest 2011; 139: 555–562.
Sağlık Bakanlığı Rehberi (2021). COVID-19 (SARS-CoV-2 Enfeksiyonu) Erişkin Hasta Tedavisi (01/02/2022 tarihinde https://covid19.saglik.gov.tr/TR-66926/eriskin-hasta-tedavisi.html adresinden ulaşılmıştır).
World Health Organization 2020. Clinical management of COVID(01/02/2022 tarihinde https://www.who.int/teams/health-care-readiness-clinical-unit/covid-19 adersinden ulaşılmıştır).
Netea MG, Giamarellos-Bourboulis EJ, Domínguez-Andrés J, et al. Trained immunity:a tool for reducing susceptibility to and the severity of SARS-CoV-2 infection. Cell 2020; 181(5): 969–977.
Garcia-Vidal C, Sanjuan G, Moreno-García E, et al. Incidence of co-infections and superinfections in hospitalized patients with COVID-19: a retrospective cohort study. Clin. Microbiol. Infect 2021; 27: 83–88.
Handbook of COVID-19 Prevention and Treatment 2020. (01/02/2022 tarihinde https://www.iau-aiu.net/Zhejiang-University-Handbook-of-COVID-19-Prevention-and-Treatment adresinden ulaşılmıştır).
Zhang G, Hu C, Luo L, et al. Clinical features and short-term outcomes of 221 patients with COVID-19 in Wuhan, China. J Clin Virol 2020; 127:104364.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. Off Clin Pract Guideline Am Thor Soc Inf Dis Soc Am , Am J Respirat Crit Care Med 2019; 200:e45–e67.
Kreitmann L, Monard C, Dauwalder O, et al. Early bacterial co-infection in ARDS related to COVID-19. Intensive Care Med 2020; 46(9):1787–9.
Meier MA, Branche A, Neeser OL, et al. Procalcitonin-guided Antibiotic Treatment in Patients With Positive Blood Cultures: A Patient-level Meta-analysis of Randomized Trials. Clin Infect Dis 2019; 69:388–396.
Wang L, Amin AK, Khanna P, et al. An observational cohort study of bacterial co-infection and implications for empirical antibiotic therapy in patients presenting with COVID-19 to hospitals in North West London. J. Antimicrob. Chemother 2021; 76:796–803.
Mirzaei R, Goodarzi P, Asadi M, et al. Bacterial co-infections with SARS-CoV-2. IUBMB Life 2020; 72(10):2097–111.
Manohar P, Loh B, Leptihn S. Will the overuse of antibiotics during the Coronavirus pandemic accelerate antimicrobial resistance of bacteria? Infect Microbe Dis. 2020; 2:87–8.
Getahun H, Smith I, Trivedi K, et al. Tackling antimicrobial resistance in the COVID-19 pandemic. Bull World Health Organ 2020; 98(7): 442.
Seaton RA, Gibbons CL,Cooper L, et al. Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals. J Infect 2020; 81(6):952-960.
Clancy CJ, Nguyen MH . Coronavirus Disease 2019, Superinfections, and antimicrobial development: what can we expect? Clin Infect Dis 2020; 17;71(10):2736-2743
Dhesi Z, Enne VI, Brealey D, et al. Organisms causing secondary pneumonia in COVID-19 patients in 5 UK ICUs as detected with the FilmArray test.medrXiv; 2020 [accessed 2021 Jul 13]
Westblade LF, Simon MS, Satlin MJ. Bacterial Coinfections in Coronavirus Disease 2019. Trends in Microbiology 2021. 29;10, 930-41.
Cox MJ, Loman N, Bogaert D,et al. Co-infections: potentially lethal and unexplored in COVID-19. Lancet Microbe 2020; 1(1):e11
Hendaus MA, Jomha FA. Covid-19 induced superimposed bacterial infection. J Biomol Struct Dyn 2021; 39(11):4185-4191
He Y, Li W, Wang Z, et al. Liu Nosocomial infection among patients with COVID-19: A retrospective data analysis of 918 cases from a single center in Wuhan. China Infect Control Hosp Epidemiol 2020; 41(8):982-983
Kim D, Quinn J, Pinsky B, et al. Brown Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. JAMA 2020; 26;323(20):2085-2086
Wang L, He W, Yu X, et al. Coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up. J Infect 2020; 80(6):639-645
Das R, Kotra K, Singh P, et al. Alternative Treatment Strategies for Secondary Bacterial and Fungal Infections Associated with COVID-19. Infect Dis Ther 2021;22;1-25
Beović B, Doušak M, Ferreira-Coimbra J, et al. Antibiotic use in patients with COVID-19: a ‘snapshot’ Infectious Diseases International Research Initiative (ID-IRI) survey. J Antimicrob Chemother 2020; 1;75(11):3386-3390
Ginsburg AS, Klugman KP. COVID-19 pneumonia and the appropriate use of antibiotics. Lancet Glob Health 2020; 8(12):1453-1454.
Rawson TM, Moore LSP, Zhu N, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing. Infectious Diseases Society of America 2020. 3;71(9):2459-2468
Iversen K, Ihlemann N, Gill SU, et al. Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis. N Engl J Med 2019; 380:415–424.
Li H-K, Rombach I, Zambellas R, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med 2019; 380:425–436.
Rawson TM, Moore LSP, Castro-Sánchez E, et al. COVID-19 and the potential long term impact on antimicrobial resistance. J Antimicrob Chemother 2020; 75(7):1681-1684
Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395:507–513.
Greenberg N, Docherty M, Gnanapragasam S, et al. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020; 368:m1211
Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. BMJ 2020; 368:m1211
Huttner BD, Catho G, Pano-Pardo JR, et al. COVID-19: don’t neglect antimicrobial stewardship principles! Clin Microbiol Infect 2020; 26(7):808–810.
