VIII. The Rational Use of Antibiotics to Prevent Secondary Infection
COVID-19 is a disease of viral infection, therefore antibiotics are not recommended to prevent
bacterial infection in mild or ordinary patients; it should be used carefully in severe patients
based on their conditions. Antibiotics can be used with discretion in patients who have the
following conditions: extensive lung lesions; excess bronchial secretions; chronic airway
diseases with a history of pathogen colonization in the lower respiratory tract; taking
glucocorticoids with a dosage<! 20 mg x 7d (in terms of prednisone). The options of antibiotics
include quinolones, the second or third generation cephalothins, ~-lactamase inhibitor
compounds, etc. The antibiotics should be used for the prevention of bacterial infection in
critically severe patients, especially those with invasive mechanical ventilation. The
antibiotics such as carbapenems, ~-lactamase inhibitor compounds, linezolid and
vancomycin can be used in critically ill patients according to the individual risk factors.
The patient's symptoms, signs and indicators such as blood routine, c-reactive protein, and
procalcitonin, need to be closely monitored during the treatment. When the change of a
patient's condition is detected, a comprehensive clinical judgment needs to be made. When
the secondary infection cannot be ruled out, qualified specimen need to be collected for
testing by smear preparation, cultivation, nucleic acid, antigen and antibody, in order to
determine the infectious agent as early as possible. Antibiotics can be empirically used in the
following conditions: (D more expectoration, darker sputum color, especially yellow pus
sputum; al the rise of body temperature which is not due to exacerbation of the original
disease; @the marked increase of white blood cells and/or neutrophils; ® procalcitonin;;, 0.5
ng/mL; ® Exacerbation of oxygenation index or circulatory disturbance that are not caused
by the viral infection; and the other conditions suspiciously caused by bacteria infections.
Some COVID-19 patients are at the risk of secondary fungal infections due to weakened
cellular immunity caused by viral infections, the use of glucocorticoid and/or broad-spectrum
antibiotics. It is necessary to do respiratory secretions microbiological detections such as
smear preparation and cultivation for critically ill patients; and provide timely D-Glucose
(G-test) and galactomannan (GM-test) of blood or bronchoalveolar lavage fluid for suspected
patients.
It is necessary to be vigilant with possible invasive candidiasis infection and anti-fungal
therapy. Fluconazole or echinocandin can be used in the following conditions: (D patients are
given broad-spectrum antibiotics for seven days or more; al patients have parenteral
nutrition; @ patients have invasive examination or treatment; ® patients have positive
candida culture in the specimen obtained from two body parts or more; ® patients have
significantly increased results of G-test.
It is necessary to be vigilant with possible invasive pulmonary aspergillosis. Anti-fungal
therapy such as voriconazole, posaconazole, or echinocandin are considered to be used in
the following conditions: (D patients are given glucocorticoid for seven days or more; al
patients have agranulocytosis; @ patients have chronic obstructive pulmonary disease and
aspergillus culture are tested positive in the specimen obtained from the airway;® patients
have significantly increased results of GM-test.
IX. The Balance of Intestinal Microecology and Nutritional Support
Some COVID-19 patients have gastrointestinal symptoms (such as abdominal pain and
diarrhea) due to direct viral infection of the intestinal mucosa or antiviral and anti-infective
drugs. There has been report that the intestinal microecological balance is broken in
COVID-19 patients, manifesting a significant reduction of the intestinal probiotics such as
lactobacillus and bifidobacterium. Intestinal microecological imbalance may lead to
bacterial translocation and secondary infection, so it is important to maintain the balance of
intestinal microecology by microecological modulator and nutritional support.
Microecologics Intervention
(1) Microecologics can reduce bacterial translocation and secondary infection. It can
increase dominant gut bacteria, inhibit intestinal harmful bacteria, reduce toxin
production and reduce infection caused by gut microflora dysbiosis.
(2) Microecologics can improve the gastrointestinal symptoms of patients. It can reduce
water in feces, improve fecal character and defecation frequency, and reduce diarrhea
by inhibiting intestinal mucosa I atrophy.
(3) The hospital with relevant resources can perform intestinal flora analysis. Therefore,
the intestinal flora disturbance can be discovered early according to the results.
Antibiotics can be adjusted timely and probiotics can be prescribed. These can reduce
the chances of intestinal bacterial translocation and gut-derived infection.
(4) Nutrition support is an important means to maintain intestinal microecological
balance.Intestinal nutrition support should be applied timely on the basis of effective
evaluations of nutritional risks, gastroenteric functions, and aspiration risks.
Nutrition Support
The severe and critically ill COVID-19 patients who are in a state of severe stress are at
high nutritional risks. Early evaluations of nutrition risk, gastrointestinal functions and
aspiration risks, and timely enteral nutritional support are important to the patient's
prognosis.
(1) Oral feeding is preferred. The early intestinal nutrition can provide nutritional
support, nourish intestines, improve intestinal mucosa I barrier and intestinal immunity,
and maintain intestinal microecology.
(2) Enteral nutrition pathway. Severe and critically ill patients often harbor acute
gastrointestinal damages, manifested as abdominal distension, diarrhea, and
gastroparesis. For patients with tracheal intubation, intestinal nutrition tube indwelling
is recommended for post-pyloric feeding.
(3) Selection of nutrient solution. For patients with intestinal damage, predigested
short peptide preparations, which are easy for intestinal absorption and utilization, are
recommended. For patients with good intestinal functions, whole-protein preparations
with relatively high calories can be selected. For hyperglycemia patients, nutritional
preparations which are beneficial to glycemic controlling are recommended.
(4) Energy supply. 25-30 kcal per kg body weight, the target protein content is 1.2-2.0
g/kg daily.
(5) Means of nutritional supply. Pump infusion of nutrients can be used at a uniform
speed, starting with a low dosage and gradually increasing. When possible, the
nutrients can be heated before feeding to reduce intolerance.
(6) The elderly patients who are at high aspiration risks or patients with apparent
abdominal distention can be supported by parenteral nutrition temporarily. It can be
gradually replaced by independent diet or enteral nutrition after their condition
improves
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