Antibiotics for Pneumonia: COVID-19 guideline

Antibiotics treatment for bacterial pneumonia in adults in hospital

Antibiotic management of suspected or confirmed bacterial pneumonia in adults in hospital during the COVID-19 pandemic. This includes people presenting to hospital with moderate to severe community-acquired pneumonia and people who develop pneumonia while in hospital.

COVID-19 pneumonia

COVID-19 pneumonia with superadded bacterial infection

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Tests to guide decisions about using antibiotics

Consider the following tests to help inform decision making about using antibiotics:

Microbiological samples for routine culture and sensitivities (for example, sputum or tracheal aspirate sample, blood culture).

SARS-CoV2 polymerase chain reaction (PCR) assay (nasopharyngeal aspirate, nose and throat swabs, or a lower respiratory tract sample if obtainable).
chest imaging (X-ray, CT or ultrasound).
full blood count.
legionella and pneumococcal antigen tests (urine sample).

Procalcitonin

There is insufficient evidence to recommend routine procalcitonin testing to guide decisions about antibiotics. The most appropriate threshold for procalcitonin is also uncertain.

C-Reactive Protein (CRP)

Be aware that high C-reactive protein levels do not necessarily indicate that the pneumonia is due to bacteria rather than COVID-19.

Published data and clinical opinion suggest that many patients with COVID-19 have raised C-reactive protein levels, meaning that this does not necessarily indicate that there is a bacterial infection.

Initial approach to antibiotic treatment choices

Be aware that:

When a patient first presents with suspected pneumonia, it is difficult to differentiate between COVID-19 pneumonia and bacterial pneumonia on clinical features alone.

During the COVID-19 pandemic to date most pneumonia has been viral. Evidence so far suggests that bacterial co-infection occurs in less than about 10% of patients with COVID-19. But patients in critical care have an increased likelihood of bacterial infection compared with patients in other hospital wards or settings.

Because COVID-19 pneumonia is caused by a virus, antibiotics are ineffective unless there is a bacterial co-infection.

Inappropriate antibiotic use may reduce their availability, and indiscriminate use may lead to Clostridioides difficile infection and antimicrobial resistance.

When to start antibiotics?

If there is confidence that the clinical features are typical for COVID-19, it is reasonable not to start empirical antibiotics.

Empirical antibiotics should be started if there is clinical suspicion of bacterial infection, including characteristic symptoms and localised chest findings.

A neutrophil count outside the normal range or lobar consolidation on chest imaging may suggest a bacterial infection but their absence does not exclude it. When a decision to start antibiotics has been made:

Start empirical antibiotic treatment as soon as possible after establishing a diagnosis of pneumonia, and certainly within 4 hours.
Do not wait for microbiological test results.
Start treatment within 1 hour if the patient has suspected sepsis and meets any of the high-risk criteria.

Antibiotic choice Table 1

To guide decision making about antibiotics, use:

Antibiotic prescribing table 1 for patients with suspected community-acquired pneumonia (that is, pneumonia that has developed before or within 48 hours of admission).

Antibiotics for people 18 and older with suspected community-acquired pneumonia [amended 9 October 2020]

Empirical treatment

Antibiotics and dosage (oral doses are for immediate-release medicines)

Oral antibiotics for moderate or severe pneumonia

Options include:

Doxycycline: 200 mg on first day, then 100 mg once a day

Amoxicillin + Clavulanate: 500 mg/125 mg three times a day with

Clarithromycin: 500 mg twice a day

In severe pneumonia, and if the other options are unsuitable:

Levofloxacin: 500 mg once or twice a day (consider the safety issues with fluoroquinolones)

Intravenous antibiotics for moderate or severe pneumonia

Options include:

Amoxicillin + Clavulanate: 1.2 g three times a day with

Clarithromycin: 500 mg twice a day

Cefuroxime: 750 mg three times a day (increased to 750 mg four times a day or 1.5 g three or four times a day if infection is severe) with

Clarithromycin: 500 mg twice a day

In severe pneumonia and if the other options are unsuitable:

Levofloxacin: 500 mg once or twice a day (consider the safety issues with fluoroquinolones)

Antibiotic choice Table 2

To guide decision making about antibiotics, use:

Antibiotic prescribing table 2 for patients with suspected hospital acquired pneumonia (that is, pneumonia that develops 48 hours or more after admission and that was not incubating at admission).

Antibiotics for people 18 and older with suspected hospital-acquired pneumonia

Empirical treatment	Antibiotics and dosage (oral doses are for immediate-release medicines)
Oral antibiotics for non-severe pneumonia when there is not a higher risk of resistance	Options include: Doxycycline: 200 mg on first day, then 100 mg once a day Amoxicillin + Clavulanate: 500 mg/125 mg three times a day Co-trimoxazole: 960 mg twice a day (see the BNF for information on monitoring of patient parameters) If the other options are unsuitable: Levofloxacin: 500 mg once or twice a day (consider the safety issues with fluoroquinolones)
Intravenous antibiotics for severe pneumonia (for example, symptoms or signs of sepsis or ventilator-associated pneumonia) or when there is a higher risk of resistance	Options include: Piperacillin with tazobactam: 4.5 g three times a day, increased to 4.5 g four times a day if infection is severe Ceftazidime: 2 g three times a day If the other options are unsuitable: Levofloxacin: 500 mg once or twice a day(use a higher dosage if infection is severe; consider the safety issues with fluoroquinolones)
Antibiotic to be added if meticillin-resistant Staphylococcus aureus infection is suspected or confirmed (dual therapy with an intravenous antibiotic listed above)	Vancomycin: 15 mg/kg to 20 mg/kg two or three times a day intravenously, adjusted according to serum vancomycin concentration. Maximum 2 g per dose (see the BNF for information on patient parameter and therapeutic drug monitoring) Teicoplanin: Initially 6 mg/kg every 12 hours for 3 doses intravenously, then 6 mg/kg once a day (see the BNF for information on patient parameter and therapeutic drug monitoring) Linezolid: 600 mg twice a day orally or intravenously (with specialist advice only; see the BNF for information on monitoring of patient parameters)

When to stop antibiotics?

Review all antibiotics at 24 to 48 hours or as soon as test results are available.

Use the following signs, symptoms and test results to help inform the overall clinical assessment and decision about when to safely stop antibiotics:

no evidence of bacterial infection in blood, urine or sputum samples.
a positive SARS-CoV2 polymerase chain reaction (PCR) assay.
fever resolved or resolving.
symptoms and blood test results (particularly lymphopenia) consistent with COVID-19 pneumonia.
chest imaging (plain X-ray, CT scan or lung ultrasound) consistent with COVID-19 pneumonia.

Be aware that the 3 patterns on CT-chest imaging consistent with COVID-19 pneumonia according to stage of illness (from symptom onset) are:

early (0 to 2 days): normal or rounded ground-glass opacities.
intermediate (5 to 10 days): crazy-paving opacities.
late (more than 10 days): consolidation.

Chest imaging changes are bilateral in most patients (more than 60%), with the lung periphery and lower lobes being most involved. Early ground-glass appearances may not be visible on plain chest X-rays.

Continue antibiotics if there is clinical or microbiological evidence of bacterial infection, regardless of SARS-CoV2 PCR test results.