Should antibiotics (abx) be given for pneumonia with a viral appearance?

From the Guidelines

Antibiotics should be given for pneumonia with a viral appearance if there is a high suspicion of bacterial co-infection, the patient is severely ill, immunocompromised, elderly, or has significant comorbidities. When deciding to prescribe antibiotics, it is crucial to weigh the risks of missing a bacterial infection against the harms of unnecessary antibiotic use, including side effects, Clostridioides difficile infection, and contribution to antimicrobial resistance 1. The IDSA/ATS 2019 guidelines recommend de-escalation of antibiotics in those with no evidence of bacterial superinfection and clinical stability after 48 to 72 hours of initiation of antibiotics 1. Some key points to consider when prescribing antibiotics for pneumonia with a viral appearance include:

• The use of empiric antibiotics in patients with COVID-19 should be guided by clinical concern for bacterial pneumonia, with a recommendation to utilize WHO Access category antibiotics where appropriate 1.
• Diagnostic tools, such as procalcitonin levels, can help identify patients with potential bacterial superinfection and guide antibiotic de-escalation 1.
• The decision to prescribe antibiotics should be reassessed after 48-72 hours based on clinical response and any available culture results 1.
• Common regimens for pneumonia with a viral appearance include azithromycin or amoxicillin, with consideration of a respiratory fluoroquinolone like levofloxacin for patients with risk factors for drug-resistant pathogens 1. It is essential to consider the unique pathobiology of critically ill patients, including altered pharmacokinetics and pharmacodynamics of antibiotics, when selecting treatment regimens 1. Ultimately, the goal is to provide timely, accurate, and empiric treatment for pneumonia with a viral appearance while minimizing the risks of unnecessary antibiotic use and promoting antimicrobial stewardship 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of azithromycin and other antibacterial drugs, azithromycin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy.

Antibiotics should only be given for pneumonia with a bacterial appearance, as the use of antibiotics is recommended for infections proven or strongly suspected to be caused by susceptible bacteria 2.

• There is no direct information in the label to support the use of antibiotics for pneumonia with a viral appearance. The decision to use antibiotics should be based on the suspicion of a bacterial cause, and the results of culture and susceptibility tests should be considered when available.

From the Research

Antibiotic Treatment for Pneumonia with a Viral Appearance

• The decision to administer antibiotics for pneumonia with a viral appearance depends on various factors, including the severity of the disease, underlying health conditions, and the potential for bacterial co-infection 3, 4.
• For non-severe community-acquired pneumonia, the addition of empiric atypical antibacterial therapy, such as a macrolide, is not always necessary and should be balanced with the potential harms of antibiotic use and the risk of selecting for antibiotic-resistant organisms 4.
• In cases where atypical coverage is deemed necessary, macrolides are a suitable choice, with azithromycin being effective in treating atypical pneumonia in adult patients, regardless of whether it is given for 3 or 5 days at the same total dose 5.
• For moderate to severe community-acquired pneumonia, combination therapy with a third-generation cephalosporin and a macrolide may be preferred over monotherapy with a fluoroquinolone to minimize the development of multiresistant nosocomial Gram-negative bacilli 6.
• New antibiotics, such as ceftaroline and solithromycin, have shown non-inferiority in clinical efficacy compared to usual regimens, but their use should be reserved for specific cases where their unique properties, such as anti-toxin or anti-inflammatory effects, may be beneficial 7.

Key Considerations

• The potential for antibiotic resistance and the need for antimicrobial stewardship should guide antibiotic prescribing decisions 3, 4, 6, 7.
• The choice of antibiotic therapy should be based on the severity of the disease, underlying health conditions, and the potential for bacterial co-infection 3, 4, 6.
• Combination therapy with a third-generation cephalosporin and a macrolide may be preferred over monotherapy with a fluoroquinolone for moderate to severe community-acquired pneumonia 6.