What is the first-line antibiotic for treating bacterial co-infections in COVID-19 patients?

First-Line Antibiotics for Bacterial Co-infections in COVID-19 Patients

For non-critically ill COVID-19 patients with suspected bacterial co-infection, empirical antibiotics should cover both typical and atypical pathogens of community-acquired pneumonia, following local/national guidelines for CAP. 1

Assessment of Need for Antibiotics

• Bacterial co-infections are not common in all COVID-19 patients, so restrictive use of antibiotics is generally recommended, especially for mild to moderately ill patients 1
• Exceptions for restrictive antibiotic use include:
  • Patients with radiological findings and/or inflammatory markers compatible with bacterial co-infection 1
  • Severely ill patients requiring ICU admission or mechanical ventilation 1, 2
  • Immunocompromised patients 1

Diagnostic Approach Before Antibiotic Initiation

• Obtain sputum and blood cultures before starting empirical antibiotic therapy 1
• Perform pneumococcal urinary antigen testing in all patients 1
• Consider Legionella urinary antigen testing according to local/national guidelines 1
• Laboratory findings suggesting bacterial co-infection include:
  • Elevated white blood cell count 1, 2
  • Elevated C-reactive protein 1, 2
  • Procalcitonin level >0.5 ng/mL 1, 2

First-Line Antibiotic Recommendations

For Non-ICU/Non-Critically Ill Patients:

• Follow local/national guidelines for community-acquired pneumonia 1
• Recommended options include:
  • Beta-lactam (such as amoxicillin + clavulanic acid or third-generation cephalosporins) 1
  • Consider avoiding macrolides and quinolones due to cardiac side effects, especially if patient is on other QT-prolonging medications like hydroxychloroquine 1
  • If atypical coverage is needed, consider doxycycline instead of macrolides 1

For ICU/Critically Ill Patients:

• Empirical antibiotics with additional coverage for MRSA in selected patients 1
• For secondary bacterial infections in critically ill patients, consider double antipseudomonal and/or anti-MRSA antibiotics based on local epidemiology 1

Duration and De-escalation

• If cultures are negative and patient is improving, stop antibiotics after 48 hours 1
• For confirmed bacterial infections, a 7-day course is typically sufficient if the patient:
  • Has been afebrile for 48 hours 1
  • Has reached clinical stability 1
• Consider using procalcitonin levels to guide early discontinuation of antibiotics 2

Common Pathogens in COVID-19 Co-infections

• Most common pathogens are similar to those in regular bacterial CAP 1
• Reported pathogens include:
  • Streptococcus pneumoniae 1
  • Haemophilus influenzae 1
  • Staphylococcus aureus (including MRSA) 1
  • Mycoplasma pneumoniae (most common atypical bacterial co-infection) 1

Common Pitfalls to Avoid

• Overuse of antibiotics in COVID-19 patients without evidence of bacterial co-infection can increase antimicrobial resistance 1
• Serum biomarkers alone should not determine when to start antibiotics, especially in non-critically ill patients 1, 2
• Not all radiographic abnormalities in COVID-19 patients indicate bacterial co-infection; they may be due to the viral infection alone 2