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Medication Matters Confirmed COVID-19 Pneumonia Potential Bacterial Co-infection with COVID-19 Pneumonia? Andrew Wang, Pharm.D.; BCPS, BCIDP One of the questions often asked by providers is whether a patient should be Hughes et al., performed a retrospective cohort study investigating the incidence started on antibiotics to cover for potential co-bacterial infection in patients with of bacterial and fungal co-infection of hospitalized patients in a UK secondary care Medication Matters confirmed COVID-19 pneumonia. This question stems ultimately from concerns setting. 836 laboratory-confirmed COVID-19 patients were evaluated, and it was November 2020 Pharmacy Medication Safety Alerts of co-bacterial and viral infections, as bacterial co-pathogens are commonly found that the overall incidence was 6.1% and only 3.2% for patients who were identified in viral respiratory tract infections such as influenza and are an important hospitalized 0-5 days. The most common pathogen identified was Pseudomonas cause of morbidity and mortality. In the most recent IDSA Community Acquired spp (9 patients) and S. aureus (4 patients). There was a 0% positivity rate for Pneumonia (CAP) guidelines, current literature supports that adults with clinical Legionella and streptococcal urinary antigen test. Lastly, surprisingly, Candida and radiographic evidence of CAP who test positive for influenza in the inpatient spp. was found in 21.4% of the samples; however, the authors postulated that LIFEBRIDGE HEALTH FORMULARY REVIEW COMMITTEE UPDATES and outpatient settings should be treated concurrently with antibiotics. This was this likely represented oropharyngeal thrush or normal flora rather than pulmonary LifeBridge Health Formulary Review Committee Updates based on evidence suggesting that bacterial coinfections as bacterial pneumonia candidiasis. The observational study concluded that they identified a low incidence can occur concurrently with influenza virus infection or present later as a worsening of bacterial coinfection in early COVID-19 hospitalized patients. ITEM FOR VOTE DECISION of symptoms in patients recovering from primary influenza infection, thus can be a In patients with mild-to-moderate respiratory disease consistent with COVID-19 Ravulizumab (Ultomiris) LFRC voted in favor of adding ravulizumab to formulary, making it a preferred common and serious complication of influenza. Bacterial co-infection in patients without obvious signs of bacterial infection, the likelihood of bacterial co-infection Monograph, LBH agent for adults and pediatric patients with atypical hemolytic uremic syndrome with severe influenza has been reported to be as high as 20-30% and is associated is low and antibiotics can be safely held off, even in the setting of gradual worsening with a greater severity of illness, greater use of healthcare resources, and increased and paroxysmal nocturnal hemoglobinuria, and restricting the use of eculizumab of respiratory status, as this is likely from progression of COVID-19 rather than to adults with generalized myasthenia gravis and neuromyelitis optic spectrum risk of death. superimposed secondary bacterial co-infection. If a patient develops a new or It is important to note there is a significant knowledge gap as the prevalence, acutely worsening respiratory failure, sepsis or both after initial phase of consistent disorder. incidence and characteristics of bacterial infection in patients with COVID-19 improvement, then nosocomial acquisition of secondary bacterial co-infection is Capsaicin Cream LFRC voted in in favor of adding capsaicin 0.075% cream to formulary and pneumonia are not well understood. As such, most patients are started on reasonable and empiric antibiotic therapy may be appropriate. In patients who Monograph, LBH removing capsaicin 0.025% and 0.1% cream from formulary. antibiotics given the difficulty in ruling out bacterial co-infection on presentation as are critically ill with severe respiratory failure with COVID-19, empiric antibiotic Daptomycin Dosing for LFRC voted in favor of updating policies to reflect dosing of daptomycin by well as ruling in the possibility of secondary infection during the course of illness. treatment may be reasonable and should be targeted for community-acquired As a result, many guidelines recommend the use of empirical antibiotics in severe pneumonia unless patient has risk factors for resistant pathogens. Obese Patients, LBH adjusted body weight for obese patients (BMI > 30). COVID-19 disease; however, this ultimately raises the concern of antibiotic overuse While ruling out bacterial co-infection may be difficult, procalcitonin may be helpful. Sugammadex LFRC voted in in favor of maintaining current sugammadex restrictions and not and unintended consequences. Several reported series of COVID-19 have consistently reported low procalcitonin Medication Use allowing its use outside of the operating room. Langford et al., performed a systematic review and meta-analysis that included a levels in isolated COVID-19 infections, which can be helpful in ruling out bacterial Evaluation and total of 24 studies in which 3,506 laboratory-confirmed COVID-19 patients from co-infection4. Procalcitonin is detectable in 2-4 hours, peaks at 12-24 hours and United States, Spain, China, Thailand and Singapore were evaluated. The results has a half-life of about 25-30 hours. Keep in mind that procalcitonin can be elevated Monograph Addendum, showed that overall patients who were found to have COVID-19 with bacterial co- in patients with acute respiratory distress syndrome (ARDS), end-stage renal LBH infection was 6.9% (95% CI, 4.3-9.5%). When stratified to include only critically disease (ESRD), cardiogenic shock, multi-organ failure, surgery, malignancy and Anticoagulation Clinic LFRC voted in favor of adopting the Anticoagulation Clinic policy with ill patients, the rate increased to 8.1% (95% CI, 2.3-13.8%). It was also found congestive heart failure (CHF), therefore, having an elevated level (> 0.5 mcg/L) Policy, SH, NW recommended updates and addition of direct oral anticoagulation monitoring for that 71.9% received antibiotics overall. The most common organisms reported does not necessarily correlate to bacterial infection while having a low level (<0.5 Sinai and Northwest hospitals. were Mycoplasma species (11 patients), Haemophilus influenzae (5 patients), mcg/L) make bacterial infections less likely and can guide antibiotic discontinuation. and Pseudomonas aeruginosa (5 patients). Overall, the incidence of co-bacterial Hypertonic Saline Policy, LFRC voted in favor of adopting Hypertonic Saline policy changes as proposed by At the present time, current literature supports that the overall incidence of bacterial SH, NW, CH individual hospitals (Sinai, Carroll, Northwest). infection associated with COVID-19 patients appear to be much lower than co- coinfection remains low; therefore, antibiotic therapy should be considered for those bacterial infection associated with influenza patients at the present. with clinical high suspicion of bacterial pneumonia. Investigational Drug LFRC voted in favor of adopting updates to the Investigational Drug/Study Drug Service/ Study Drug policy for Sinai Hospital. Policy, SH USP 800- Hand Hygiene LFRC voted in favor of adopting the new USP 800 hand hygiene and PPE use Simple and Effective: Adenosine Single-Syringe Administration in Supraventricular Tachycardia and PPE Use Policy, LBH policy. Xinyi Huang, Pharm.D. Candidate, University of Maryland Baltimore School of Pharmacy; Hellena Admassu, Pharm.D., BCPS, MPH - Clinical Pharmacy Specialist, Emergency Medicine, Northwest Hospital Radiopharmaceutical LFRC voted in favor of adopting/grandfathering the presented List, LBH radiopharmaceutical list to formulary for LBH. Adenosine, an endogenous purine nucleoside, decreases conduction saline in a single syringe. At the providers’ discretion, pharmacists prepared velocity in the atrioventricular node making it useful for management of adenosine and saline (2 mL + 18 mL) in a single syringe (SS arm) or in two narrow complex supraventricular tachycardias (SVT). It is metabolized by separate syringes (TS arm) (SS n = 26; TS n = 27). Patients in the SS group erythrocytes and vascular endothelial cells resulting in a very short half-life had a higher rate of successful conversion to normal sinus rhythm (NSR) at Sinai Hospital Anticoagulation Clinic: Official Center of Excellence Site (<10 seconds). To ensure adequate drug delivery to the myocardium, it must 73.1% versus 40.7% in the TS group (noninferiority, p = 0.0176). Conversion Leann Kwak, Pharm.D.,Si PGY-1mple Pharmacy and Effective:Resident Adenosine Single-Syringe Administration in be administered as a rapid intravenous bolus, followed by a 20 mL saline to NSR was 100% in the SS group after up to these doses (vs. 70.4% in TS Shari Fogelquist, Pharm.D.,Supraventricular BCACP, Clinical Pharmacist Tachycardia II flush. This administration method is logistically challenging; it requires two arm, p = 0.0043). Extravasation and phlebitis were noted in one patient in As the landscape of anticoagulation is advancing and evolving, the Anticoagulation Forum has built the first comprehensive set of standards for an anticoagulation separate syringes, a two-way stopcock and the coordinated action of staff the TS arm. service center that defines ideal practices by creating the Centers of Excellence certification program in 2012. Certification is granted through quality during administration. Xinyi Huang, PharmD Candidate Even though this study is under-powered
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