Epidemiologic, clinical, microbiologic and antimicrobial resistance (AMR) data on nosocomial superinfections during the coronavirus disease 2019 (COVID-19) pandemic is needed to inform stewardship that will be crucial for limiting broad-spectrum antimicrobial use in hospitalized patients, according to a review published in Clinical Infectious Diseases.

According to the review authors, limited data from case series indicate that it will be reasonable to anticipate that, “an appreciable minority of patients with severe COVID-19 will develop superinfections, most commonly pneumonia due to nosocomial bacteria and Aspergillus.” Therefore, widespread, broad-spectrum antimicrobial use will likely occur among hospitalized patients. In fact, through mid-February 2020, secondary infections were reported in a range of 5% to 27% of adults with COVID-19 in several hospitals in Wuhan, China, and among 13.5% to 44% of patients in the intensive care unit. Moreover, the review authors highlighted that previous literature with data from from 552 hospitals in 30 Chinese provinces, show that 58% of patients were treated with antibiotics.

Furthermore, no studies have yet investigated COVID-19-associated superinfections or AMR. Currently, congressional COVID-19 relief bills are considering antimicrobial reimbursement reforms and subscriptions models but it is not yet known if these will be included in final legislation.

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In light of this, the review authors argued that carefully designed prospective studies early on in the pandemic investigating COVID-19 superinfections are needed. Data from this type of work could then be used to inform rational antimicrobial treatment and stewardship strategies as well as develop diagnostic criteria for superinfections. They concluded that these studies can provide accurate information on antimicrobial usage and AMR throughout the pandemic. Particular attention should also be paid to high-risk groups such as transplant recipients and other immunosuppressed patients. This could help guide future efforts at market and drug development reform.

The review authors specifically recommend 2 antibiotic subscription models, Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) and the Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act for consideration in new legislation. “If DISARM or PASTEUR are not included in comprehensive COVID-19 response legislation, the issues of AMR and antimicrobial development will likely not be considered again until the new Congress in 2021.” They believe that delaying reform to this marketplace for another year, “will undoubtedly lead to more companies failing, and to further chilling of investor enthusiasm for new antibiotic development.”

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Both authors received investigator-initiated research grants from Astellas, Merck, Melinta, and Cidara for studies unrelated to this project and have served on advisory boards or consulted for Astellas, Merck, the Medicines Company, Cidara, Scynexis, Shionogi, Qpex and Needham & Company.


Clancy CJ, Nguyen MH. COVID-19, superinfections and antimicrobial development: What can we expect? [published online May 1 2020]. Clin Infect Dis. doi:10.1093/cid/ciaa524. 

This article originally appeared on Infectious Disease Advisor