The rapidly escalating coronavirus disease 2019 (COVID-19) pandemic has focused attention on the diagnosis and treatment of patients with acute respiratory infection in an unprecedented manner. Although most of the lung injury patients have is believed to be caused by the virus, concern over bacterial co-infection also informs current treatment approaches for patients with COVID-19–related pneumonia.

1. Empirical coverage for bacterial pathogens is recommended in patients with CAP without confirmed COVID-19 but is not required in all patients with confirmed COVID-19–related pneumonia.

Community-acquired pneumonia is diagnosed in patients with signs and symptoms of respiratory infection (especially cough, sputum production, and fever) and radiographic evidence of lung involvement. The cause of CAP includes a range of bacteria and viruses.

The new guideline continues to emphasize prompt antibacterial drug therapy for all patients diagnosed with CAP. Antibacterial therapy continues to be featured so prominently in CAP guidelines because before the COVID-19 pandemic, bacterial causes of CAP were associated with the highest mortality and empirical antibacterial therapy is proven to be effective and save lives.

2. Although data are limited, it is likely that the relevant bacterial pathogens in patients with COVID-19 and pneumonia are the same as in previous patients with CAP and therefore empirical antibiotic recommendations should be the same.

The bacterial pathogens responsible for CAP are reflective of the bacteria that often colonize the upper airway and opportunistically infect the lung during a respiratory illness. Therefore, authors believe the same range of pathogens, including Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia pneumoniae, and Staphylococcus aureus, should be considered in patients with COVID-19–related pneumonia.

For low-risk inpatients, the guideline recommends a β-lactam (penicillins, cephalosporins, monobactams, carbapenems) plus either a macrolide (azithromycin or clarithromycin) or doxycycline as combination therapies or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) as monotherapy.

For high-risk inpatients (typically those in the intensive care unit), the guideline recommends a β-lactam plus macrolide or β-lactam plus fluoroquinolone. The Authors believe these same recommendations apply to patients with COVID-19.

3. Testing for bacterial pathogens with sputum and blood cultures is most useful when there is concern for multidrug-resistant pathogens.

An additional issue addressed by the CAP guideline was multidrug-resistant pathogens, specifically Pseudomonas aeruginosa and methicillin-resistant S aureus. The guideline recommends that in all cases when more expanded antibiotic therapy is initiated, blood and sputum cultures should be obtained to confirm or rule out the presence of these pathogens. If results of cultures are negative and the patient is improving, the expanded therapy for P aeruginosa and methicillin-resistant S aureus should be narrowed within 48 hours of starting therapy.

4. Procalcitonin could be helpful in limiting overuse of antibiotics in patients with COVID-19–related pneumonia.

No procalcitonin threshold perfectly distinguishes viral from bacterial pneumonia. Procalcitonin may also be elevated in patients with COVID-19 because of generalized inflammatory activation rather than bacterial co-infection. Still, authors endorse the use of a low procalcitonin value early in the course of confirmed COVID-19 illness to guide the withholding or early stopping of antibiotics, especially among patients with less severe disease. Perhaps more important, 5 days of antibiotic therapy is adequate for most patients with CAP.

5. Although it is likely that host immunologic processes play a key role in the lung damage that leads to respiratory failure and adverse outcomes in patients with COVID-19, immunomodulating therapy is not currently recommended in patients with pneumonia.

Before COVID-19, much attention was given to the potential benefits of adding corticosteroids to the treatment of adults with CAP. However, on the basis of a review of published studies, the guideline committee ultimately recommended against using corticosteroids in patients with CAP. Authors also do not currently recommend corticosteroids or other immunomodulating therapies as adjunct treatments for patients with COVID-19–related pneumonia.

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