Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

ABSTRACT

Introduction

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

Methods

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

Results

A total of 284 patients were included, most were male (66.9%), aged 30–50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the ‘Watch’ category (90.8%) followed by the ‘Reserve’ category (4.8%), similar to previous COVID-19 waves.

Conclusion

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

KEYWORDS:

• Antibiotics
• AWaRe classification
• antibiotic stewardship programs
• COVID-19
• hospitalized patients
• tertiary care
• Pakistan

Article highlights

• In the first five waves of COVID-19 in Pakistan, there was appreciable prescribing of antibiotics in patients admitted with COVID-19, averaging 89.69% of patients among tertiary hospitals despite only 1.14% of patients having proven bacterial co-infections and 3.14% secondary infections. Alongside this, there was appreciable prescribing of ‘Watch’ antibiotics, averaging 93.35% of total antibiotics prescribed

• There were similar concerns in the sixth wave, with approximately 91% of patients admitted to tertiary hospitals prescribed antibiotics during their hospital stay, with again only a limited number with proven bacterial co-infections or secondary bacterial infections

• Most antibiotics prescribed were from the ‘Watch’ category (90.8%) followed by the ‘Reserve’ category (4.8%) with limited prescribing of ‘Access’ antibiotics

• This is a major concern, with the WHO advocating that at least 60% of antibiotics prescribed in given settings should be from the ‘Access’ list

• Consequently, there is an urgent need to instigate pertinent antimicrobial stewardship programs (ASPs) in hospitals in Pakistan to reduce high rates of inappropriate prescribing of antibiotics especially from the ‘Watch’ and ‘Reserve’ list. This includes patients admitted with COVID-19 in successive waves

• ASPs have been successfully introduced in other LMICs and can serve as exemplars to all key stakeholder groups in Pakistan going forward

Declaration of interest

The authors have no 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. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

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

Ethics statement

Ethical approval for the study was obtained from the Office of Research, Innovation and Commercialization (ORIC), Lahore College for Women University, Jail Road, Lahore. Reference number, ORIC/LCWU/54 with approvals also sought from the administration of participating hospitals.

Data availability statement

Additional data is available from the corresponding authors on reasonable request.

Author contribution statement

Concept and Methodology: ZUM, AB, MS, JCM, BG, CEM. Investigation/Data Collection: ZUM, AB, HI, MS, YHK, THM. Data analysis and verification: All authors; Visualization: ZUM, AB, MS, JCM; writing original draft: ZUM, BG, CEM; writing – Review and Editing: All authors. Project supervision and administration: ZUM, BG.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14787210.2023.2299387

Additional information

Funding

This paper was not funded.