Superinfections in patients treated with Teicoplanin as anti‐SARS‐CoV‐2 agent

Abstract

We read with interest the paper by Giacobbe et al estimating a cumulative risk of developing at least one bloodstream infection (BSI) episode (largely due to Gram-positive pathogens) of almost 50% after 30 days at risk in severe COVID-19 patients. 2 Similarly, Somers et al reported an increased risk to develop bacterial superinfections, principally represented by Staphylococcus aureus ventilatory associated pneumonia (VAP), in critically ill patients infected with SARS-CoV-2 and treated with tocilizumab.1 We previously described a cohort of intubated patients affected by SARS-CoV-2 pneumonia treated with the best available therapy (BAT), including tocilizumab, and associated with teicoplanin.3 This glycopeptide antibiotic was used with a double purpose: as antiviral agent for COVID-19 and as empiric treatment of possible S aureus superinfection since the latter may represent a major complication of respiratory viral infections.4, 5 The study showed that only 19% (4/21 subjects) of patients treated with BAT plus tocilizumab and teicoplanin had an isolation of methicillin-resistant/teicoplanin-susceptible S aureus from respiratory secretions, and none had Gram-positive superinfections.5 Here, we reported an update of the previous data, analysing bacterial infections in a retrospective multicentric cohort study enrolling 55 mechanically ventilated, SARS-CoV-2-infected patients treated with BAT and tocilizumab (Tei-COVID Study). Reporting of the study conforms to broad EQUATOR guidelines.6 For 34 subjects, treatment included also a median of 8-day (range 6-12) course of teicoplanin administration (6 mg/kg every 24 hours with loading dose every 12 hours for three doses, started on ICU admission). Ad interim BAT was compliant with suggestion of the Italian Society of Infectious and Tropical Diseases (SIMIT) and largely based on hydroxychloroquine 200 mg twice/daily plus Azithromycin 500 mg daily.7 Tocilizumab 8 mg/kg (up to a maximum of 800 mg/dose) twice with an interval of 12 hours was administered in all patients. As showed in Table 1, Gram-positive superinfections were less frequent in teicoplanin-treated group than in untreated and their incidence in teicoplanin-treated was lower than that observed in other studies.1, 2 In particular, among 34 patients treated, 35% (12/34) developed a superinfection and only 16% BSIs and 6% bacterial lung superinfections due to Gram-positive pathogens. The 21 teicoplanin-untreated patients had an incidence of Gram-positive superinfections, comparable to what Somers and Giacobbe previously reported. Interestingly, we observed a higher number of Gram-negative BSI and VAP probably related to the changes in the abundance of aerobic bacteria in the intestinal microbiota associated with administration of teicoplanin and SARS-CoV-2 infection.8, 9 Nevertheless, the higher number of Gram-negative superinfections observed in teicoplanin-treated group could be also influenced by a longer follow up time (median 20 days, range 4-39) than that of the other studies. Superinfection N° isolates/pts Causative microbiology↓ BSI 12/34 VAP 31/34 BSI 12/21 VAP 18/21 BSI 12/78 VAP 41/78 BSI 8/76 VAP 22/76 BSI 23/18 BSI 22/60 Based on our data, the use of teicoplanin could have represented a contributing factor in the reduction of the incidence of Gram-positive superinfections in mechanically ventilated patients with COVID-19. Further investigations are needed to clarify the possible impact of teicoplanin on host microbiome and on the possible development of glycopeptide resistance in this setting. On the other hand, teicoplanin role as an antiviral agent for COVID-19 still remains under investigation. None to declare.

Topics & Concepts