Coronavirus disease 2019 (COVID-19) and antibiotic stewardship: Using a systems engineering approach to maintain patient safety

To the Editor—In the absence of effective treatments for coronavirus disease 2019 (COVID-19), many hospitalized COVID-19 patients receive antibiotics.1,2 Thus far, the literature does not indicate that antibiotics are effective in treating COVID-19, and the incidence of bacterial coinfections appears low.2 One analysis reported that while 8% of COVID-19 patients experienced a bacterial or fungal coinfection, 72% of COVID-19 patients received antibiotics.2 Clostridioides difficile infection (CDI) is associated with broad-spectrum antibiotics frequently used for COVID-19; CDI is thus a significant concern for COVID-19 patients.3 Patients at higher risk of severe COVID-19 frequently also have risk factors for CDI such as advanced age and weakened immune systems.3 COVID-19 treatments themselves, which often involve extended hospital stays, can also increase a patient’s risk of developing healthcare-associated CDI.3 CDI has been identified in patients who received antibiotics as part of their COVID-19 treatment.4,5 Given the patient safety risks posed by CDI, effective antibiotic stewardship remains critical throughout the COVID-19 pandemic. The length of hospitalization for many patients increases risks of developing healthcare-acquired infections such as ventilator-associated pneumonia that may require additional antibiotic treatment.7 These factors, combined with a lack of effective treatment options for severe COVID-19, have resulted in high levels of antibiotic use among COVID-19 inpatients.1,2 The structure and effectiveness of an antibiotic stewardship program is dependent on the individual work-system context, including characteristics of the patient population, organizational culture toward antibiotic stewardship, availability of infectious disease and pharmacy personnel, accessibility of clinical decision support tools, and existing policies to support antibiotic stewardship. The interaction of these elements influences care processes and outcomes.8 Given the urgent needs to ensure appropriate antibiotic use and reduce CDI risk in COVID-19 patients, a systems engineering approach such as SEIPS can be used to understand the various work-system factors that are involved in antibiotic stewardship and CDI prevention. Practices to Support Antibiotic Stewardship and Reduce CDI in the Care of COVID-19 Patients SEIPS Element Antibiotic Stewardship Practice Person(s) Avoid antibiotic use unless patient is severely ill or in case of bacterial coinfection Priori