Coronavirus disease 2019 (COVID-19): Secondary bacterial infections and the impact on antimicrobial resistance during the COVID-19 pandemic

Abstract

Secondary bacterial infections and bacterial coinfections are an important complication of coronavirus disease 2019 (COVID-19), leading to antibiotic overuse and increased rates of antimicrobial resistance (AMR) during the COVID-19 pandemic. In this literature review, we summarize the reported rates of secondary bacterial infections and bacterial coinfections in patients with COVID-19, the impact on patient outcomes, the antibiotic treatment approaches employed, and the resistance patterns observed. The reported data suggest that although the incidence of secondary bacterial infections or bacterial coinfections is relatively low, they are associated with worse outcomes such as prolonged hospitalization, intensive care unit admission, mechanical ventilator use, and increased mortality. Interestingly, antibiotic prescription rates are typically higher than secondary bacterial and bacterial coinfection rates, and reports of AMR are common. These findings highlight the need for an improved understanding of secondary bacterial and bacterial coinfection in patients with COVID-19, as well as improved treatment options, to mitigate inappropriate antibiotic prescribing and AMR.

Fig. 1.

Common etiologies of bacterial coinfections and/or secondary bacterial infections in patients with COVID-19. The most frequently reported bacterial microorganisms from 22 studies (up to 5 of the most common bacterial microorganisms) were included for each type of infection from each study: 6 studies for CA infection, ^,,,,, 12 studies for HA infection, ^,,,,,,,–, and 6 studies for both CA and HA ^,,,– (studies could report >1 type of infection). The number of studies that reported each organism are shown in parenthesis. Note. CA, community-acquired; COVID-19, coronavirus disease 2019; HA, hospital-acquired.

Fig. 2.

Proportion of patients with COVID-19 receiving antibiotics: (a) in patients with COVID-19 and carbapenemase-producing Enterobacterales; (b) in patients with carbapenem-resistant Klebsiella pneumoniae; (c) in patients with COVID-19 and bloodstream infection; (d) in patients with carbapenem-resistant Pseudomonas aeruginosa for suspected bacterial superinfection; and (e) in patients with COVID-19 and bacterial infection. Note. CA, community-acquired; COVID-19, coronavirus disease 2019; HA, hospital-acquired.

Fig. 3.

Most frequently used antibiotics in patients with COVID-19.^a (a) Studies expressed data as percentage of patients receiving antibiotic treatments, except the study by Langford et al, in which data were presented as percentage of prescriptions of an antibiotic class per total number of antibiotic prescriptions. Data are provided only for antibiotic classes that were used in >10% of patients or > 10% of prescriptions. Note. β-LI, β-lactamase inhibitors; COVID-19, coronavirus disease 2019.