Abstract
Despite the low rates of bacterial co-/superinfections in COVID-19 patients, antimicrobial drug use has been liberal since the start of the COVID-19 pandemic. Due to the low specificity of markers of bacterial co-/superinfection in the COVID-19 setting, overdiagnosis and antimicrobial overprescription have become widespread. A quantitative and qualitative evaluation of urinary tract infection (UTI) diagnoses and antimicrobial drug prescriptions for UTI diagnoses was performed in patients admitted to the COVID-19 ward of a university hospital between 17 March and 2 November 2020. A team of infectious disease specialists performed an appropriateness evaluation for every diagnosis of UTI and every antimicrobial drug prescription covering a UTI. A driver analysis was performed to identify factors increasing the odds of UTI (over)diagnosis. A total of 622 patients were included. UTI was present in 13% of included admissions, and in 12%, antimicrobials were initiated for a UTI diagnosis (0.71 daily defined doses (DDDs)/admission; 22% were scored as ‘appropriate’). An evaluation of UTI diagnoses by ID specialists revealed that of the 79 UTI diagnoses, 61% were classified as probable overdiagnosis related to the COVID-19 hospitalization. The following factors were associated with UTI overdiagnosis: physicians who are unfamiliar working in an internal medicine ward, urinary incontinence, mechanical ventilation and female sex. Antimicrobial stewardship teams should focus on diagnostic stewardship of UTIs, as UTI overdiagnosis seems to be highly prevalent in admitted COVID-19 patients.
Highlights
Antimicrobial resistance (AMR) is one of the biggest threats in the modern era of human and veterinary medicine
We found high rates (61%) of inappropriate urinary tract infection (UTI) diagnoses, which resulted in a significant proportion of unnecessary antimicrobial use for UTIs diagnosed by the treating physician
Reyes et al came with a warning concerning probable overdiagnosis and overtreatment of asymptomatic bacteriuria in COVID-19 patients, as they cited the Infectious Disease Society of America (IDSA), which recommends ‘the assessment for other causes and watchful observation of older patients with functional and/or cognitive impairment with bacteriuria and without local genitourinary symptoms rather than immediate antimicrobial treatment’
Summary
Antimicrobial resistance (AMR) is one of the biggest threats in the modern era of human and veterinary medicine. In order to counter antimicrobial overprescribing, antimicrobial stewardship teams need reliable data concerning antimicrobial prescriptions in admitted COVID-19 patients, as well as better diagnostic markers of bacterial co-/superinfection and enhanced decision support systems. Since the start of the pandemic, different studies have highlighted disproportional antimicrobial use in COVID-19 patients despite low bacterial co- and superinfection rates. Reported rates vary from 4 to 19%, depending on the geographical setting of the study, the inclusion or exclusion of patients admitted to the intensive care unit and the used definitions of co-/superinfections [4,5,6,7,8,9].
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