Antibiotic Use in COVID-19 Patients with Suspected Bacterial Co-infection

Introduction to Antibiotic Use

For non-critically ill COVID-19 patients with suspected bacterial co-infection, empirical antibiotics should cover both typical and atypical pathogens of community-acquired pneumonia, following local/national guidelines for CAP 1

Bacterial co-infections are not common in all COVID-19 patients, so restrictive use of antibiotics is generally recommended, especially for mild to moderately ill patients 2, 3
Exceptions for restrictive antibiotic use include patients with radiological findings and/or inflammatory markers compatible with bacterial co-infection 3
Severely ill patients requiring ICU admission or mechanical ventilation may require antibiotic use 1, 4
Immunocompromised patients may also require antibiotic use 3

Obtain sputum and blood cultures before starting empirical antibiotic therapy 2, 3
Perform pneumococcal urinary antigen testing in all patients 2
Consider Legionella urinary antigen testing according to local/national guidelines 2
Laboratory findings suggesting bacterial co-infection include elevated white blood cell count 1, 4
Elevated C-reactive protein is also a laboratory finding suggesting bacterial co-infection 1, 4
Procalcitonin level >0.5 ng/mL is another laboratory finding suggesting bacterial co-infection 1, 4

For non-ICU/non-critically ill patients, follow local/national guidelines for community-acquired pneumonia 1, 2
Recommended options include beta-lactam (such as amoxicillin + clavulanic acid or third-generation cephalosporins) 5, 2
Consider avoiding macrolides and quinolones due to cardiac side effects, especially if patient is on other QT-prolonging medications like hydroxychloroquine 5
If atypical coverage is needed, consider doxycycline instead of macrolides 5
For ICU/critically ill patients, empirical antibiotics with additional coverage for MRSA in selected patients may be necessary 1
For secondary bacterial infections in critically ill patients, consider double antipseudomonal and/or anti-MRSA antibiotics based on local epidemiology 1

If cultures are negative and patient is improving, stop antibiotics after 48 hours 2, 3
For confirmed bacterial infections, a 7-day course is typically sufficient if the patient has been afebrile for 48 hours and has reached clinical stability 1
Consider using procalcitonin levels to guide early discontinuation of antibiotics, although this should be done with caution and consideration of individual patient factors 4

Overuse of antibiotics in COVID-19 patients without evidence of bacterial co-infection can increase antimicrobial resistance 5, 2
Serum biomarkers alone should not determine when to start antibiotics, especially in non-critically ill patients 1, 4
Not all radiographic abnormalities in COVID-19 patients indicate bacterial co-infection; they may be due to the viral infection alone 4