Fluoroquinolones Are Not Recommended for COVID-19 Treatment
Fluoroquinolones are not recommended for treating COVID-19 as there is no evidence supporting their direct antiviral efficacy against SARS-CoV-2, and they should only be used when bacterial co-infection is confirmed or strongly suspected. 1
Bacterial Co-infection in COVID-19
- Bacterial co-infections in COVID-19 patients are less common than initially thought, making empiric antibiotic therapy unnecessary in most confirmed COVID-19 cases 1
- The relevant bacterial pathogens in COVID-19 patients with pneumonia are likely the same as in other community-acquired pneumonia (CAP) patients, including Streptococcus pneumoniae, Haemophilus influenzae, Chlamydia pneumoniae, and Staphylococcus aureus 1
- Data on the prevalence of bacterial superinfection in COVID-19 patients are very limited, making it difficult to justify routine antibiotic use 1
Recommendations for Antibiotic Use in COVID-19
When Antibiotics Should Be Considered:
- Empirical antibiotic coverage is recommended in patients with suspected but unconfirmed COVID-19 who present with pneumonia 1
- Antibiotics should be considered when bacterial co-infection cannot be ruled out based on clinical manifestations, especially in severe cases 1
- Procalcitonin can be helpful in limiting overuse of antibiotics in COVID-19 patients, with low values supporting withholding or early stopping of antibiotics 1
Choice of Antibiotics When Needed:
- If antimicrobial treatment is necessary, a beta-lactam (e.g., amoxicillin + clavulanic acid or third-generation cephalosporins) should be the first option 1
- For low-risk inpatients, guidelines recommend either:
- A β-lactam plus a macrolide (azithromycin or clarithromycin) or doxycycline as combination therapy, OR
- A respiratory fluoroquinolone (levofloxacin or moxifloxacin) as monotherapy 1
- For high-risk inpatients (typically ICU patients), guidelines recommend β-lactam plus macrolide or β-lactam plus fluoroquinolone 1
Cautions Regarding Fluoroquinolones in COVID-19
- Fluoroquinolones and macrolides should generally be avoided due to their cardiac side effects, especially when combined with other COVID-19 treatments like hydroxychloroquine that may also affect cardiac function 1
- If atypical coverage is needed, doxycycline should be considered instead of fluoroquinolones 1
- Despite theoretical in silico studies suggesting potential antiviral activity of fluoroquinolones against SARS-CoV-2, there is no clinical evidence supporting their direct efficacy against the virus 2, 3
- Unnecessary antibiotic use in COVID-19 patients may increase the risk of subsequent hospital-acquired pneumonia caused by resistant bacteria 1
Duration and De-escalation of Antibiotics
- If antibiotics are started empirically, they should be discontinued or de-escalated within 48 hours if cultures are negative and the patient is improving 1
- For most patients with pneumonia, 5 days of antibiotic therapy is adequate 1
- Antimicrobial treatment should be targeted based on culture results with de-escalation as early as possible 1
Common Pitfalls to Avoid
- Prescribing antibiotics for all COVID-19 patients without evidence of bacterial co-infection contributes to antimicrobial resistance 4
- Despite early pandemic practices, continued use of antimicrobials (including fluoroquinolones) in outpatient settings should be avoided as there is no justifiable rationale 4
- Relying on in silico or theoretical studies without clinical evidence to support fluoroquinolone use specifically for COVID-19 treatment 2, 3
- Failing to consider the potential cardiac side effects of fluoroquinolones, especially when used in combination with other COVID-19 treatments 1, 5
In conclusion, while fluoroquinolones remain an important option for treating bacterial pneumonia, they have no proven direct activity against SARS-CoV-2 and should only be used in COVID-19 patients when there is clear evidence of bacterial co-infection or high clinical suspicion warranting empiric coverage.