Treating RTIs in the era of COVID-19

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Use antibiotics judiciously, say experts

Before the COVID-19 pandemic emerged, we were contending with another global public health threat: antimicrobial resistance (AMR). The coronavirus may not only have diverted our attention from fighting AMR, it may have worsened the threat by leading to an increased use of antibiotics.

“AMR may not feel, right now, as acute a public health threat as COVID-19, but certainly, in the long-term, it should not be regarded as any less serious in terms of impact,” said Dr. Jerome Leis, medical director of infection prevention and control at Sunnybrook Health Sciences Centre.

“This is not a time to be throwing caution to the wind in terms of our antibiotic use,” said Dr. Leis, “and, in fact, in the context of the pandemic, we may even be seeing an acceleration of this very important public health threat.”

As COVID-19 is a virus, there is no role for antibiotics in the management of mild cases in the community. However, a review of data from COVID-19 cases, mostly in Asia, found more than 70 percent of patients received antimicrobial treatment despite less than 10 percent, on average, having bacterial or fungal coinfections. Statistics, such as these, have given rise to fear among scientists that increased antibiotic use during the pandemic could increase the long-term threat of AMR.

In Canada, AMR figures are cause for very real concern, said Dr. Leis. More than 14,000 deaths in Canada in 2018 were associated with resistant infections. Of these, 5,400 deaths were directly attributable to AMR. The Council of Canadian Academies projects “the cumulative number of lives lost in Canada between 2020 and 2050 that will be attributable to AMR would range between just under 256,000 if resistance to first-line antimicrobials stayed at today’s rates of 26 percent, to just over 396,000 if there is a gradual increase to 40 percent resistance.”

“AMR may not feel, right now, as acute a public health threat as COVID-19, but certainly, in the long-term, it should not be regarded as any less serious in terms of impact”

Unnecessary antibiotic use is a direct contributor to antimicrobial resistance. Over 23 million antibiotic prescriptions are written for human consumption in Canada, 30-50 percent of which are estimated to be unnecessary.

In 2017, Choosing Wisely Canada (CWC) launched the “Using Antibiotics Wisely” campaign to help clinicians and patients engage in conversations about unnecessary antibiotic use. The campaign’s message going into this year’s respiratory infection season is particularly important, says Dr. Leis, who spoke at a CWC webinar entitled, “The Cold Standard: A Practical Approach to Managing Respiratory Tract Infections.” The CWC updated its Cold Standard Kit to reflect the context of the evolving COVID-19 pandemic and the challenges it presents to primary care providers.

“I think we can all agree that we are entering a respiratory virus season unlike any other that we have encountered before, where we have a COVID-19 pandemic that will be co-circulating with other respiratory viruses and where primary care has shifted, to a large part, to virtual care,” said Dr. Leis, who is also clinical lead of the “Using Antibiotics Wisely” campaign.

An initial visit with a patient who may have a respiratory tract infection (RTI) is still likely to be virtual, given what primary care physicians are telling CWC, says Dr. Leis. At that visit, it should be determined whether the patient needs a COVID-19 test — and the threshold for that decision should be low. It should also be determined whether the patient should be seen in person.

The guidance in the Cold Standard Kit states in-person care should occur whenever necessary. Most Canadians are fully vaccinated and personal protective equipment is no longer a significant barrier, it states. The Cold Standard Kit provides guidance on what presentations can be handled virtually and what presentations should be seen in person.

If antibiotics are being considered during a virtual visit, then an in-person assessment is strongly recommended. “There are very, very few reasons why we should be prescribing antibiotics in a virtual visit,” said Dr. Olivia Ostrow, patient safety lead for the Division of Pediatric Emergency Medicine at the Hospital for Sick Children, who participated in a second CWC webinar entitled, “Curbing Unnecessary Antibiotic Use in Children: Navigating Colds, Flu, and Kids This Respiratory Season.”

For those RTIs that may be bacterial, an in-person assessment for examination is required to make the diagnosis (e.g., to assess the tympanic membrane, to determine need for a throat swab or chest x-ray) and determine if antibiotics are warranted. When they are deemed necessary, the duration should not exceed maximum recommendations.

But if you are frequently prescribing antibiotics for patients with acute RTI syndromes, you are likely overprescribing, said Dr. Ostrow. The majority of patients with RTI in a primary care setting do not benefit from antibiotics and these may cause unnecessary harms, she said.

“We are entering a respiratory virus season unlike any other that we have encountered before”

Most acute respiratory tract infections are viral and can be managed with supportive care, whether virtual or in-person, said Dr. Ostrow. Assessing patients in person does not change the fact that the majority of RTIs do not require antibiotics.

Supportive management can be offered using the campaign’s viral prescription. This prescription — now available in a version for pediatric patients, as well as adults — addresses patient concerns through structured communication regarding RTI diagnosis, symptom management, expected clinical course and safety net planning.

Another clinical tool developed by CWC is the delayed prescription, which can be used for cases with diagnostic uncertainty regarding bacterial infection (e.g., acute otitis media). If symptoms persist, the parent can take the post-dated prescription to the pharmacy to be filled. In two-thirds of the cases, the parent does not end up filling the prescription.

Dr. Ostrow says research found that encouraging parents to use a viral prescription or a delayed prescription only adds 42 seconds to an appointment’s duration. This finding debunks the myth that it takes too much time to explain to patients why an antibiotic is not in their best interest.

“This is not a knowledge issue, prescribers know how to diagnose bacterial infections and viral infections,” said Dr. Leis. “This is more about the process, the approach and the clinical tools we’ve developed to address the known barriers to judicious use of antibiotics.”