Antibiotic Use in COVID-19 Management

Role of Doxycycline

The American College of Physicians recommends against routine prescription of antibiotics, including doxycycline, for COVID-19 patients, and suggests that antibiotic use should be based on clinical justifications such as disease manifestations, severity, imaging findings, and laboratory data 1, 2, 3
Empirical antibiotic coverage for bacterial pathogens is recommended in patients with community-acquired pneumonia (CAP) without confirmed COVID-19, but is not required in all patients with confirmed COVID-19-related pneumonia, according to the Infectious Diseases Society of America 4, 5
When bacterial co-infection is suspected in non-critically ill COVID-19 patients, empirical antibiotics should cover both typical and atypical pathogens, with doxycycline being one option in combination with a β-lactam, as suggested by the American Thoracic Society 4, 6, 7

Doxycycline may be considered as part of combination therapy with a β-lactam when treating suspected bacterial co-infections in COVID-19 patients, particularly for coverage of atypical pathogens, according to the Infectious Diseases Society of America 4, 6, 7
For low-risk inpatients with suspected bacterial co-infection, a β-lactam plus either a macrolide or doxycycline are recommended combination therapies, as suggested by the Society of Critical Care Medicine 6, 7
For high-risk inpatients, guidelines recommend β-lactam plus macrolide or β-lactam plus fluoroquinolone rather than doxycycline, according to the American College of Chest Physicians 6

If antibiotics including doxycycline are initiated, obtain blood and sputum cultures to confirm or rule out bacterial pathogens, as recommended by the Infectious Diseases Society of America 4, 1
Use procalcitonin levels to guide antibiotic therapy decisions - a low procalcitonin value (<0.25 ng/mL) early in the course of confirmed COVID-19 can help guide withholding or early stopping of antibiotics, according to the American Thoracic Society 1, 8, 5
If culture results are negative and the patient is improving, antibiotic therapy should be narrowed or discontinued within 48 hours of starting therapy, as suggested by the Society of Critical Care Medicine 4, 8

Indiscriminate use of antibiotics like doxycycline for COVID-19 may contribute to antimicrobial resistance, which remains a significant long-term concern, according to the World Health Organization 9
Macrolides and quinolones should generally be avoided due to cardiac side effects, especially when other agents with cardiac side effects are being used, and doxycycline may be preferred when atypical coverage is needed, as recommended by the American Heart Association 9
If antimicrobial treatment is considered necessary, a 5-day course of antibiotic therapy is adequate for most patients with CAP, including those with COVID-19, according to the American College of Physicians 5