ABSTRACT
STATEMENT OF PROBLEM/QUESTION: To review empiric antibiotic usage in COVID-19 patients and highlight the involvement of the antimicrobial stewardship (AMS) team to reduce unnecessary antibiotic days DESCRIPTION OF PROGRAM/INTERVENTION: Majority of deaths during the H1N1 pandemic were attributed to secondary bacterial respiratory infections but data regarding superinfections in COVID-19 pneumonia is still emerging. During the COVID-19 pandemic, most physicians started empiric antibiotics in patients with COVID-19. We reviewed adult patients with COVID-19 admitted to Northwestern McHenry Hospital from November 2020 to January 2021. AMS team was actively involved in reviewing antibiotics and using electronic medical records (EMR) prompts and secure texting system to recommend discontinuation of antibiotics where there were no signs of bacterial infection. We also analyzed whether early discontinuation led to any adverse event/readmission. MEASURES OF SUCCESS: - Reduction in empiric antibiotic usage in cases of COVID-19 where clinical suspicion for bacterial co-infection is low - Role of AMS team intervention in the reduction of unnecessary antibiotic usage FINDINGS TO DATE: 61 patients were reviewed, all were started on antibiotics in emergency department which were continued beyond 24 hours. 41 (67.21%) met sepsis criteria on admission day;20 (32.78%) did not meet sepsis criteria;3 (4.91%) had suspected bacterial pulmonary co-infection based on clinical and imaging findings;1 had suspected aspiration pneumonia and 1 had culture-positive UTI. Most common antibiotics used were Ceftriaxone (n=61,100%), Doxycycline (n=44,72.13%), Azithromycin (n= 15,24.59%), Piperacillin/Tazobactam (n=4,6.56%) and Vancomycin (n=1,1.64%). Using EMR prompts and texts, days of unnecessary antibiotics saved were 46 days for 40 patients, presuming patients would have received at least 5 days of empiric antibiotics without AMS team intervention. Intervention on Day 2 of admission saved 32 days of unnecessary antibiotics for 18 patients and intervention after day 2, 14 days of antibiotics were saved for 22 patients. KEY LESSONS FOR DISSEMINATION: The pandemic has amplified antibiotic prescriptions increasing concern for antibiotic resistance. AMS team can play a pivotal role as gatekeepers for the appropriate use of antimicrobials. In our analysis, no patients had adverse events related to early discontinuation of antibiotics during the same hospitalization, and only 4 (6.56%) patients had readmission related to secondary bacterial pulmonary infection. Despite being on antibiotics for 7 days, these patients developed secondary bacterial infection implying that antibiotics do not seem to be beneficial in preventing secondary infection. We observed maximum benefit when the AMS team intervened on Day 2 of admission which resulted in more days of unnecessary antibiotics saved. AMS team can be actively involved in developing guidelines, tracking toxicities, early de-escalation/discontinuation, and antibiotic “time outs” via EMR. We encourage a multidisciplinary approach to improve antibiotic stewardship in COVID-19.
ABSTRACT
CASE: A 25 year old Vietnamese female initially presented to the emergency department (ED) with progressive dyspnea and cough for 2 weeks. Chest Xray (CXR) showed left lower lobe consolidation and was started on a 5-days of azithromycin. She returned to ED 3 days later with a worsening cough, yellowish sputum, dyspnea, pleuritic chest pain, chills, appetite loss, and a 6-pound weight loss. 7 years ago her pre-immigration screening was negative for tuberculosis. She worked in a nail salon and did gardening as a hobby. On exam, she was afebrile, appeared dyspneic with normal oxygen saturation, diminished breath sounds on left lower lobe with egophony. Labs showed leukocytosis of 22,300 with neutrophilia and negative COVID-19 test. Repeat CXR showed worsening left lower lobe opacity. On day 3, temperature peaked at 103.1F with worsening sputum production. Computed tomography (CT) chest showed complete consolidation of the left lower lobe with tree-in-bud opacities in bilateral upper lobes and right lower lobe. Antibiotics were switched from ceftriaxone and azithromycin to piperacillin-tazobactam and vancomycin. Bronchoalveolar lavage (BAL) gram stain, acid-fast bacilli stain and gomori stain, and blood cultures were negative. Follow-up CT chest was worse and repeat bronchoscopy with biopsy was done. On day 8, urinary blastomyces and histoplasma antigen tests were positive. BAL cytology showed budding yeast consistent with blastomycosis. IV voriconazole was added and her symptoms gradually improved. She was discharged on 6-month course of oral voriconazole. BAL and biopsy cultures came back positive for B. dermatitidis confirming the diagnosis. Outpatient follow-up with CXR after a month showed both clinical and radiological improvement. IMPACT/DISCUSSION: Blastomycosis is a fungal infection caused by thermally dimorphic fungi Blastomyces species, endemic in Ohio, Mississippi River Valleys, and the Great Lakes region in the United States. It commonly presents as a pulmonary infection following inhalation of spores. Severity varies from asymptomatic to life-threatening acute respiratory distress syndrome. Diagnosis delay is common with frequent misdiagnoses including bacterial pneumonia, malignancy, and tuberculosis. Pulmonary blastomycosis commonly presents as dense consolidation in the upper lobes but can have variable presentation. Serological tests, cultures and BAL studies can aid in diagnosis. Repeat bronchoscopies should be considered when the suspicion is high. Of note, blastomyces antigen can have cross-reactivity with histoplasma antigen which might be the case with our patient. CONCLUSION: This case highlights the resemblance of clinical and radiological presentation of blastomycosis with other respiratory conditions and the need for timely diagnosis, treatment, and antimicrobial stewardship. Practitioners need to keep a strong suspicion of this disease in patients with atypical presentation for pneumonia especially in endemic areas.