Should antibiotics be prescribed for a patient with Covid-19 (Coronavirus disease 2019) and suspected bacterial sinusitis?

Antibiotic Management for COVID-19 Patients with Sinusitis

Antibiotics should not be routinely prescribed for patients with COVID-19 and suspected sinusitis unless there are specific clinical justifications such as disease manifestations, disease severity, radiographic imaging, and laboratory data supporting bacterial co-infection. 1

Decision Algorithm for Antibiotic Use

When to Consider Antibiotics

• Antibiotics should be prescribed only when there is clinical evidence of bacterial sinusitis in a COVID-19 patient, not routinely for all COVID-19 patients 1
• Clinical justifications that warrant antibiotic therapy include:
  • Critically ill patients requiring ICU admission or mechanical ventilation 1, 2
  • Radiological findings compatible with bacterial co-infection 1, 3
  • Laboratory markers suggesting bacterial infection:
    • Elevated white blood cell count 1, 2
    • Significantly elevated C-reactive protein 2, 3
    • Procalcitonin level >0.5 ng/mL 1, 2
  • Prolonged or worsening sinusitis symptoms despite appropriate COVID-19 treatment 1, 4

Diagnostic Approach Before Starting Antibiotics

• Obtain comprehensive microbiologic workup before starting empirical antibiotics 1
• Collect appropriate specimens for culture (sputum, blood) 1, 3
• Perform pneumococcal urinary antigen testing 1, 3
• Consider Legionella urinary antigen testing according to local guidelines 1, 3

Antibiotic Selection for Confirmed/Strongly Suspected Bacterial Sinusitis

First-Line Options

• For non-critically ill COVID-19 patients with bacterial sinusitis:
  • Amoxicillin as first-line therapy (10-14 days) 4, 5
  • Amoxicillin-clavulanate for patients with recent antibiotic use or no response to amoxicillin within 72 hours 4, 5

For Penicillin-Allergic Patients

• Mild disease: Trimethoprim/sulfamethoxazole or doxycycline 4, 6
• Moderate disease: Respiratory fluoroquinolones (levofloxacin, moxifloxacin) 7, 8

For Critically Ill Patients

• Consider broader coverage including anti-MRSA antibiotics 1, 3
• Follow local guidelines for community-acquired pneumonia with sinusitis 1, 3

Monitoring and De-escalation

• Stop antibiotics when:
  • Cultures show no bacterial pathogens after 48 hours of incubation 1, 3
  • Patient shows clinical improvement with resolution of signs, symptoms, and inflammatory markers 1
• Suggested antibiotic duration is 5 days upon improvement of signs, symptoms, and inflammatory markers 1, 2

Common Pathogens in COVID-19 with Bacterial Sinusitis

• Streptococcus pneumoniae 7, 5
• Haemophilus influenzae 7, 5
• Moraxella catarrhalis 7, 5
• Staphylococcus aureus (including MRSA in severe cases) 3, 9

Important Caveats and Pitfalls

• Overuse of antibiotics in COVID-19 patients can lead to antimicrobial resistance 1, 10
• 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 3, 10
• Long-term steroid use for COVID-19 may increase risk for secondary bacterial infections, including multidrug-resistant sinusitis 10, 9
• Concurrent COVID-19 and complicated bacterial sinusitis may have higher rates of surgical intervention requirements 9