Prevalence of bacterial coinfection and patterns of antibiotics prescribing in patients with Covid-19: a systematic review and meta-analysis

Introduction: Evidence on prevalence of bacterial coinfection in Coronavirus Disease 2019 (COVID-19) is controversial; previous global viral respiratory pandemics reported high prevalence of bacterial coinfection, which was associated with increased risk of morbidity and mortality (1). Data on Prevalence of antibiotic prescribing in COVID-19 indicates high antibiotic prescribing, causing a potential setback in antimicrobial stewardship and potential increase in antimicrobial resistance (2). The study protocol was registered in the international register of systematic reviews, PROSPERO, under the following ID: CRD42021261734

Aim: To determine the prevalence of bacterial coinfection and antibiotic prescribing in COVID-19 patients

Methods: Systematic review and meta-analysis was conducted using Covidence. Data were extracted by one reviewer. Proportion data was pooled using random effects meta-analysis approach using STATA 17; and stratified based on region and study design. Data Source: OVID MEDLINE, OVID EMBASE, Cochrane and MedRxiv between January 2020 and June 2021. Study Eligibility: English language studies of laboratory-confirmed COVID-19 patients which reported (a) prevalence of bacterial coinfection and/or (b) prevalence of antibiotic prescribing with no restrictions to study designs or healthcare setting. Participants: Adults with RT-PCR confirmed diagnosis of COVID-19

Results: A total of 1058 studies were screened, of which 22 studies were eligible. Retrospective cohort studies accounted for the majority of the studies involved (n = 18, 81%), whilst prospective cohort studies accounted for the remaining (n=4, 18%). Of the 22 studies included, 3 (13%) studies were pre-prints, whilst the remaining (n=19, 86%) were peer-reviewed. A total of 13 (59%) studies were conducted in multicentre settings, whilst the remaining (n=9, 40%) were conducted in single centre settings. All of the studies included were conducted in hospital setting, whether it be in a normal, isolation or an intensive care ward. Twenty-one out of 22 studies have been rated "Good" rating during the quality assessment process. Pooled estimates for the prevalence of bacterial co-infection and antibiotic use were 5.62% (95% CI 2.26 – 10.31) and 61.77% (CI 50.95 – 70.90), respectively.

Conclusion: The prevalence of bacterial coinfection amongst COVID-19 patients is low (5.62%) when compared with previous pandemics, yet antibiotic prescribing in COVID-19 patients was high (61.77%) indicating the need for stronger antimicrobial stewardship to reduce the global threat of AMR. Prescribing of antibiotics in COVID-19 should be based on clinical and/or laboratory evidence of bacterial coinfection. Key strengths of this review, is that it included a comprehensive search strategy spanning over several databases, including both pre-prints and peer-reviewed studies. Limitations in this review was that during the screening process, a significant number of studies have been excluded due to not meeting the inclusion criteria, therefore, bacterial coinfection and antibiotic use may be under- or over-reported. In addition, disproportionate representation from North America and failure to include studies from regions other than Europe and Asia, can limit the generalizability of the results to other regions impacted by COVID-19.