Table 2.

Possible AMS solutions for COVID-19 patients.

Emergency room • Correct respiratory sample to rule out coinfection • New rapid diagnostic tests or traditional microbiology processing, including blood culture, S. pneumoniae and Legionella urinary antigen a • Other samples for other aetiologies (i.e. urinary tract infections) • Screening swabs (i.e. rectal or nasal) according to hospital policy and in patients with risk factors for MDR organisms • Other consults from specialists in cases of non-infectious diagnosis (i.e. heart failure) • Stop corticosteroids if started too early in the course of the disease • Hold therapy unless high clinical suspicion (laboratory examinations, radiology support) • Avoid antibiotic therapy in patients if recently hospitalized and without evidence of coinfection • Continuous staff training

Medical ward • Monitor epidemiological situation during COVID-19 pandemic • Obtain cultures when indicated – even if difficult • Use surveillance cultures and extra contact precautions according to the results • Use risk stratification for MDR organisms • If started, antibiotic therapy should be chosen according to local epidemiology a • Apply pharmacokinetic/pharmacodynamic principles • Every 24 h, therapy should be reviewed to stop or de-escalate antimicrobial treatment • Early switch from IV to oral therapy • Antibiotics should be stopped after 5–7 days for respiratory tract infections, upon improvement of signs, symptoms and inflammatory markers • Continuous staff training

ICU • Monitor epidemiological situation during COVID-19 pandemic • Correct sampling to rule out secondary infections, including BAL • New rapid diagnostic tests or traditional microbiology processing for bacteria • Use comprehensive diagnostic approach with fungal testing on BAL (histology, culture, galactomannan and Aspergillus PCR) (1,3)-β-d-glucan and radiology awareness when IFI is suspected • Excluding fibrosis or pulmonary embolism as alternative diagnosis: keep high index of suspicion and low threshold for contrast enhanced CT scan • Use surveillance cultures and extra contact precautions according to the results • Reserve antimicrobials for confirmed infections and challenge the concept of routine antibiotic coverage in patients admitted to the ICU because of COVID-19 • Use risk stratification for MDR organisms • If started, antibiotic therapy should be chosen according to local epidemiology a • Apply pharmacokinetic/pharmacodynamic principles. Check interactions and secondary toxicities if using azoles • Every 24 h, therapy should be reviewed to stop or de-escalate antimicrobial treatment • Early switch from IV to oral therapy is possible • Antibiotics should be stopped after 5–7 days for respiratory tract infections, upon improvement of signs, symptoms and inflammatory markers • Continuous staff training

BAL, bronchoalveolar lavage; CAPA, COVID-19-associated pulmonary aspergillosis; CT, computed tomography; MDR, multidrug-resistant.

^aAccording to the criteria mentioned in local and national guidelines for CAP.