Empiric antibiotic use confers no therapeutic benefit in COVID-19 pneumonia
The use of empiric antibiotic therapy appears to prevent neither deterioration nor death among patients with COVID-19 pneumonia, as shown in this study.
Take Home Message
In a group of patients with COVID-19 pneumonia, antibiotics were commonly started in those who were severely ill. Patients who did vs did not receive antibiotics more often developed diarrhoea (34.7 percent vs 11.8 percent) and had slightly higher subsequent admissions to the intensive care unit (ICU; 8.0 percent vs 4.9 percent).
Furthermore, antibiotic treatment did not result in lower 30-day or in-hospital rates in an analysis that controlled for age, comorbidities, and severity of COVID-19 illness.
The best performing inflammatory marker for predicting bacterial infections was the C-reactive protein (CRP) level although the sensitivity and specificity were <90 percent.
When COVID-19 intersects with other respiratory viruses
“COVID-19 imposes challenges in antibiotic decision-making due to similarities between bacterial pneumonia and moderate to severe COVID-19,” according to the investigators.
The typical symptoms of COVID-19 pneumonia, such as fever, cough and dyspnoea, often prompt clinicians to start empiric antibiotic treatment while waiting for diagnostic testing such as a SARS-CoV-2 polymerase chain reaction test, radiology, and blood investigations.
The investigators also noted that even if COVID-19 is confirmed, it is common that empiric antibiotics are continued pending further evaluation if the treating physician is not able to conclude that bacterial co-infections have been adequately excluded.
The patients treated with antibiotics in the current study were more likely to have diarrhoea. What is more is the concern that widespread unnecessary antibiotic use will subject patients to the risks of adverse effects and worsening of antimicrobial resistance globally.
International guidelines recommend that cultures be obtained prior to antibiotics and that therapy be accessed daily for de-escalation,” according to the investigators. “When microbiology cultures are negative, antibiotics should be discontinued.”
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Background:
COVID-19 imposes challenges in antibiotic decision-making due to similarities between bacterial pneumonia and moderate to severe COVID-19. We evaluated the effects of antibiotic therapy on the clinical outcomes of COVID-19 pneumonia patients and diagnostic accuracy of key inflammatory markers to inform antibiotic decision-making.
Methods:
An observational cohort study was conducted in patients hospitalised with COVID-19 at the National Centre for Infectious Diseases and Tan Tock Seng Hospital, Singapore, from January to April 2020. Patients were defined as receiving empiric antibiotic treatment for COVID-19 if started within 3 days of diagnosis.
Results:
Of 717 patients included, 86 (12.0%) were treated with antibiotics and 26 (3.6%) had documented bacterial infections. Among 278 patients with COVID-19 pneumonia, those treated with antibiotics had more diarrhoea (26, 34.7% vs. 24, 11.8%), while subsequent admissions to the intensive care unit were not lower (6, 8.0% vs. 10, 4.9%). Antibiotic treatment was not independently associated with lower 30-day or in-hospital mortality rates after adjusting for age, co-morbidities and severity of COVID-19 illness. Compared to white cell count and procalcitonin level, the C-reactive protein level had the best diagnostic accuracy for documented bacterial infections. However, the sensitivity and specificity were less than 90%.
Conclusion:
Empiric antibiotic use in those presenting with COVID-19 pneumonia did not prevent deterioration or mortality. More studies are needed to evaluate strategies to diagnose bacterial co-infections in these patients.
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