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As the Covid-19 pandemic continues into its second year, public health experts are increasingly concerned that the response to this global crisis may be accelerating another one: the development and persistence of the antibiotic-resistant bacteria known as superbugs. Why? All antibiotic use hastens the emergence of resistance. And although antibiotics aren’t used to treat Covid-19, which is a viral illness, they’re often prescribed to Covid-19 patients who are at risk for bacterial infection.

New research from our organization, the Pew Charitable Trusts, sheds additional light on the extent to which antibiotics are being prescribed unnecessarily in the midst of the pandemic. In a study of nearly 6,000 hospital admissions between February and July 2020 among patients with Covid-19, at least one course of antibiotics was given to more than half (52%) during their hospital stays.

Patrick Skerrett / STAT Source: The Pew Charitable Trusts.

That’s significantly greater than the percentage of those patients who had bacterial infections. In just 20% of admissions, patients were diagnosed with suspected or confirmed bacterial pneumonia, and only 9% were diagnosed with a community-acquired urinary tract infection. The actual number of cases of such bacterial infections is probably even lower based on the was the study was conducted.

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This disparity between the number of patients treated with an antibiotic and those who actually needed one is at least partly explained by the fact that the vast majority of patients who received antibiotics were given their first course within 48 hours of admission — before medical personnel would typically know the result of diagnostic tests for bacterial infection.

Patrick Skerrett / STAT Source: The Pew Charitable Trusts.

Although prescribing antibiotics before a bacterial infection has been confirmed to be helpful for providing timely care for infections such as sepsis, it can also unnecessarily expose patients to antibiotics. This, in turn, jeopardizes patient safety and accelerates the emergence of drug-resistant pathogens. For example, hospitalized Covid-19 patients are sometimes prescribed broad-spectrum antibiotics, which are known to accelerate resistance, or other antibiotics that put them at high risk for getting Clostridioides difficile infections, which can result in life-threatening diarrhea. The Centers for Disease Control and Prevention has estimated that as many as 35,000 Americans die each year from antibiotic-resistant infections.

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To help minimize these risks, health care providers have been ramping up antibiotic stewardship programs over the past decade. Such programs focus on ensuring that the right antibiotic is prescribed in a timely fashion, at the appropriate dose, and for the proper duration. They also use data, such as negative bacterial cultures, to determine when an antibiotic treatment should be adjusted or ended. The CDC reports that 89% of hospitals nationwide had implemented such programs as of 2019, up from 48% in 2015.

Findings from Pew’s study suggest that antibiotic stewardship programs may be helping optimize patient care even in the midst of the pandemic. Of admissions where an antibiotic was prescribed, only 28% of them resulted in a course of antibiotics being administered both before and after the first 48 hours in the hospital. This finding indicates that when enough time had passed for physicians to receive test results, they likely determined that no further antibiotics were needed for patients without bacterial infections.

Here are three key takeaways for policymakers and public health leaders:

Ensure that hospital stewardship programs continue to receive adequate resources. Even before the pandemic, antibiotic stewardship programs had proved effective in reducing resistance rates, lowering health care costs, and improving patient outcomes. Pew’s research highlights the value of these programs, which are essential to preserving the effectiveness of existing antibiotics, and demonstrates their essential role in protecting public health. Federal and state policymakers should ensure sufficient funding to support continued expansion and improvement of stewardship programs across the country. In addition, leaders of hospitals and health systems must make sure that stewardship efforts are prioritized in individual facilities and allocate the resources required.

Take action to reinvigorate the development of urgently needed antibiotics. The pipeline of new antibiotics is woefully insufficient, and the acceleration of resistance resulting from increased antibiotic use during this pandemic makes the need for new antibiotics even more critical. One immediate step Congress can take is to pass the Pioneering Antimicrobial Subscriptions To End Up Surging Resistance (PASTEUR) Act of 2020. It aims to jump-start the development of new antibiotics, which are urgently needed to address unmet patient needs, by changing the way the U.S. government pays for these treatments.

Policymakers should also consider options to reform how hospitals are paid for administering antibiotics, either through regulatory changes to inpatient payment policies driven by the Centers for Medicare and Medicaid Services (CMS), or by legislative ideas like those proposed in the Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act, to ensure that insurers pay hospitals a fair rate for antibiotics. DISARM would let Medicare reimburse hospitals for antibiotics above the rates set for a particular diagnosis if they have an antibiotic stewardship program and report antibiotic resistance data to the CDC. Reimbursement reform would help stabilize the market and improve access to these lifesaving drugs.

Continue to make the fight against antibiotic-resistant bacteria a national priority. Among the many lessons of the Covid-19 pandemic is the importance of public health preparedness. Unlike the case of Covid-19, which took much of the world by surprise, we already know that the emergence of new, increasingly resistant bacteria is inevitable; after the events of the past year, there is no excuse for not being ready. In the U.S., that would require, among other steps, aggressive implementation of the national action plan for combating antibiotic-resistant bacteria, which was updated in October 2020; sufficient funding for the agencies and programs essential to the fight against superbugs; and a commitment to strengthening our public health infrastructure and data reporting capabilities.

Although some progress has been made in fighting antibiotic resistance, as it stands today, the U.S. is not adequately prepared to meet the threat — one that grows more serious each day. There is no time to waste to turn that around.

David Hyun, an infectious diseases physician, is the project director and Rachel Zetts is an officer with the Pew Charitable Trusts’ antibiotic resistance project.

Hear Hyun and Zetts talk more about superbugs in an episode of the “First Opinion Podcast.”

  • Optimizing Genomic Testing for Antibiotic Resistance: Performance of the Unyvero HPN by Opgen.Inc was evaluated against standard of care (SoC) microbiological testing for detection of bacterial pathogens in lower respiratory tract specimens obtained from hospitalized COVID-19 patients with a clinical suspicion of secondary bacterial infection. Final results of this study have now been published in the European Journal of Clinical Microbiology & Infectious Diseases and found that the Unyvero HPN panel provides accurate detection of common agents of bacterial pneumonia with an overall high negative predictive value of 99.8% for pathogen detection. This could potentially allow for reduction in unnecessary antibiotic use and supporting antibiotic stewardship efforts.

  • This article lacks nuance or mention of autopsy reports from NY and other initial hotspots showing that many Covid-19 pneumonia victims has superimposed bacteria on top of the viral induced parenchymal lung damage. I agree that floor patients with Covid-19 pneumonia don’t necessarily need antibiotics, but septic and ill Covid-19 patients on step down units or in the ICU should be looked at with a bit less stringent anti antiobiotic bias.

    • Also we don’t have the best tests to diagnose bacterial pneumonia in a lot of patients. We seldom get lucky isolating bacteria on sputum cultures, even in overtly lobar pneumonia patients that are not Covid patients. So there’s that also.

  • I think, we should not give antibiotics before the culture reports come , but during Covid time , so many pts hospitalized sec to their poor health & died . Obesity is a very big problem .

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