Q&A: How Bacterial Infections Can Complicate COVID-19 Cases

For a while there, it was incredibly challenging for Yi Guo, the co-director of the antimicrobial stewardship program at Albert Einstein College of Medicine. Guo also works at the pharmacy department at Montefiore Medical Center and both institutions are located in the Bronx, in New York City, the epicenter of the COVID-19 pandemic in the United States. It’s calmed down some since the spike, so Guo had a chance recently to talk to Infection Control Today^®about her experience, experience that Guo will use as a member of ICT^®’s Editorial Advisory Board. 

Infection Control Today^®:  What role does antibiotic stewardship programs play in the COVID-19 crisis?

Yi Guo, PharmD:  Normally we think that antibiotic stewardship means dealing with just antibiotics. But in this case, we are also taking care of antiviral treatments for COVID-19 patients. For example, the remdesivir,along with other possible treatments.

ICT^®:  Were other healthcare-acquired infections pushed to the side? How are they handled during the COVID crisis? Because the hospitals are so filled with COVID patients and you’re right in the epicenter of it.

Guo: We have a lot of COVID-19 patients. Our hospitals in the Montefiore Healthcare System have discharged more than 5000 patients. We know that COVID-19 is viral. It’s a SARS CoV virus. On top of this viral infection, our patients can also develop bacterial infections. Many of our patients are not only on antivirals to treat COVID-19, also on a lot of different types of antibiotics. And these patients tend to demo different infections, because there are many different risk factors. For example, prolong hospital stays, and sometimes the patient is on steroids. And also the patient is on a broad spectrum of antibiotics. Hopefully we won’t see a lot of resistant bacteria. But that’s definitely one of the key things that we are trying to prevent. Patients developing more resistant bacteria during the hospital stay.

ICT^®:  Was there a common bacterial infection that COVID-19 patients would develop?

Guo: So far, we see the average bacteria that we’re frequently dealing with, such as Staph aureus, or some of the gram negative organisms like E. colie. We do see these common infections. We see bloodstream infections and we also see pneumonia, bacterial pneumonia on top of COVID-19. And sometimes occasionally, we see a very resistant bacteria that we normally won’t see, or rarely see. We have to take them all into consideration when we take care of these types of patients…. So for Staph aureus, that bacteria is sometimes called a sticky organism. It can cause a different infection let’s say if it gets into the blood. If it gets to the bone, it can cause bone infection. If it gets to the joint, it can cause joint infection. Or the heart, it can cause a heart infection. We take that very seriously. And we want to make sure the patient receives appropriate antibiotics with the right dose and the right duration to make sure we eradicated the bacteria. And on top of Staph aureusor other gram-negative organisms, we also see fungal infections, because patients have different catheters and different lines in place. So that’s another thing that we watch out for.

ICT^®:  The spike has gone down?

Guo: The total volume of COVID patients has been going down. But we never know. There might be a second surge if we don’t practice social distancing or if we aren’t careful enough. But we still do see patients being admitted with COVID-19. On a day-to-day basis, we evaluate. How many COVID-19 patients do we have? We have different daily calls. We have the pharmacy daily call, and we try to assess the volume and try to assess our manpower. We try to see what we can do to take care of the patients. Our hospital’s regular floor converted to an ICU floor, so we can accommodate more patients as many of them need to be on a ventilator. We assess how much medication we have in hand in terms of antibiotics in terms of analgesic anesthesia. It’s a lot in play just to take care of one patient. We look at the patient while we look at the antibiotics. I will make sure the patient has the appropriate antibiotic dose for renal function. And based on the susceptibility, we also de-escalate antibiotics to treat the patient appropriately. We also evaluate who are the candidates for clinical trials for COVID-19 because my hospital also has different clinical trials going on. The FDA approved the emergency use of remdesivir. Many hospitals received remdesivir. We need to figure out who are the patients who would get the most benefit from that treatment. We established guidelines to monitor the patients. And we also have to do a lot of bookkeeping for each patient based on FDA requirements to keep the track of the lot number and make sure the proper appropriate processes are in place for us to use a drug. And Gilead also has, for example, expanded access for us to obtain medication for patients. So again, we need to screen patients to make sure these patients qualify for these studies, with the inclusion-exclusion criteria. There are a lot of patient data we need to enter for maintenance bookkeeping, to make sure we’re doing the right thing for the study. It’s a lot going on, on top of the regular management of antibiotics. But that definitely plays a huge factor because we want to make sure a patient would be treated appropriately and then we don’t want to see more and more resistant bacteria in the COVID-19 patients.

ICT^®:  Are you are you involved in the clinical trials?

Guo: We have developed a cascading system of what patients qualify for clinical trials and what patients qualify for the emergency use of remdesivir from FDA, and what patients we can enroll into the expanded access of remdesivir. So basically, there are different channels of how patients can be receiving remdesivir either through clinical trials or through compassionate use from Gilead, or through the FDA stockpile of remdesivir. We screen to make sure the appropriate patient is enrolled as quick as possible…. It’s unfortunate we do see patients who die from the disease. It’s very unfortunate, but we tried our best to take care of these patients and every second counts. These are usually patients with comorbid conditions like diabetes, hypertension, or high BMI. It’s a combination of factors. 

ICT^®:  Have you ever encountered a patient you thought wasn’t going to pull through but somehow did pull through?  

Guo: Miracles always happen. I believe in miracles. So, there are patients that we feel, “Oh, maybe we won’t be able to save this patient.” But sometimes things great things happen, and a patient turns a corner, and then the patient gets better on remdesivir, or only supportive care. We treat every patient the same, give them the best care we can provide based on their individual needs. And we pray that the patient will get better and we see patient get better at 

ICT^®:  Do you see COVID-19 as fundamentally altering how antibiotic stewardship programs proceed in the future? Or will it be basically the same method of operation?

Guo: The principle is still the same in terms of we monitor the patient, make sure the patient is on appropriate antibiotics. A lot of times, initially, we might not know what the patient has. We might start with a broad-spectrum antibiotic. But as soon as we have more data coming back, the lab result coming back, the cultures coming back, we’re able to de-escalate the antibiotic for the patient to make sure that it’s not overkill for the bacteria. I think one thing that we learned is to work closely with the infection control preventionists because when we discovered the patient has multidrug resistant bacteria, we want to make sure the appropriate isolation policy is in place. So, we will not infect a patient next door, or have our healthcare provider carry bacteria to the next-door patient. That’s something we always work very closely with infection control. And with this COVID-19, it is even more important, because everyone has to wear personal protective equipment to go into the patient’s room to take care of the patient, and just to protect the patient, protect our healthcare workers, protect each other, our family members. We want to make sure that we don’t bring the virus to others who can be at risk of having an infection as well. We work with infection control very, very closely on that. When we see there is a risk of bacteria, we’ll let our infection control team be aware so they can implement what they need to do for the patient and for the healthcare workers.

ICT^®:  Do you have daily huddles with your infection preventionists?

Guo:We have a big infectious disease call daily. That includes our infection control preventionists, including our clinical trial principal investigators, including pharmacists, including laboratory folks, because we need to test for COVID-19 by using different tests. It’s a multidisciplinary team approach. 

ICT^®:  How does someone who comes in with a viral infection develop a bacterial infection on top of that?

Guo: Sometimes a patient can have a superinfection on top of a viral infection. For example, with the fall flu. For patients who have the flu, sometimes we see the Staph aureussuperinfection on top of that. For COVID-19 SARS CoV-2 virus, we still are in the process of evaluating is this virus also associated with a particular bacterial pathogen that can cause superinfection? That data are still under evaluation, but just from what we observed just by staying in the hospital, on broad spectrum antibiotic and with different catheters-urinary catheters or a catheter for patients to receive intravenous medication-these are risk factors for patients to develop bacterial infection in the hospital. Even without COVID-19, this can happen. Now on top of COVID-19, we continue to make sure that we monitor the patient and evaluate the patient from acquiring an infection in the hospital. But if the patient develops a bacterial infection, then we have to make sure that patient is treated appropriately.

ICT^®:  During the spike were you pulling 16-hour shifts?

Guo: We have different people working on different shifts. From the pharmacists’ perspective, yes we’re working. There’s weekends and we’re still on call for taking care of the patient and we work different shifts to make sure the pharmacy is running, providing the best of care for our patients with COVID-19 or without COVID-19. Any patient who’s admitted to our hospital is our responsibility. So definitely everyone is stretched thin, and we work. We do the best we can to take care of these patients and that means that we work overtime and over the weekend. But that’s what we should do when we become a healthcare provider. 

ICT^®:  You’re in the epicenter. Any final words of advice for infection preventionists out there wondering what you went through and how you got through it?

Guo: One lesson we learned is that you need to work with your antibiotic stewardship team member and usually it’s composed of an ID physician, ID pharmacist. They are your best ally. They can provide you a lot of information and they can also help you manage patients appropriately. They are very knowledgeable in terms of what antibiotic to give to what patient for what infection. They are a great resource for infection preventionists. It’s definitely a team approach that can help us to provide the best care for our patient, and also just for the general public. I think we definitely need to continue to practice social distancing. That’s very, very important. Staying home, wash your hands, don’t touch your face. This prevents more transmission of the disease.

This interview was edited for clarity and length.