Is it good to take antibiotics for prophylaxis in viral infections?

Antibiotics Should Not Be Used for Prophylaxis in Viral Infections

Antibiotics are not recommended for prophylaxis in viral infections as they are ineffective against viruses, contribute to antimicrobial resistance, and may cause adverse effects without providing clinical benefit. 1, 2

General Principles

• Antibiotics target bacterial cellular structures and metabolic processes that are not present in viruses, making them ineffective for treating or preventing viral infections 2, 3
• Unnecessary antibiotic use contributes to antimicrobial resistance, increases treatment costs, and puts patients at risk of adverse events 2, 3
• Studies have shown that antibiotic administration does not improve disease progression or shorten hospitalization in viral infections such as COVID-19 3
• Antibiotic use disturbs the normal gut microbiome, which can impede antiviral immune responses and potentially enhance severity and susceptibility to viral infections 3

Specific Recommendations for Common Viral Infections

Respiratory Viral Infections (Common Cold, Influenza, Viral Rhinitis)

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against antibiotics for viral rhinitis as they are ineffective and do not provide symptom relief 2
• For viral upper respiratory tract infections, focus should be on symptomatic treatment with:
  • Analgesics/antipyretics (acetaminophen or NSAIDs) for pain and fever 2
  • Nasal saline irrigation for congestion relief 2
  • Short-term use of decongestants (limiting topical decongestants to 3-5 days) 2
• Antibiotics should only be considered if there is clear evidence of secondary bacterial infection, such as symptoms persisting beyond 7-10 days without improvement or worsening after initial improvement 2

COVID-19

• Despite 74.9% of COVID-19 patients receiving antibiotics during the pandemic, studies showed that bacterial coinfection occurred in only 3.5% of cases 3
• The NCCN Guidelines and other major medical organizations do not recommend routine antibacterial prophylaxis for viral infections, including COVID-19 1
• Some antibiotics, such as linezolid, may actually promote free radical production that could exacerbate clinical symptoms during and after viral infections 3

Special Populations and Considerations

Immunocompromised Patients

• For patients with cancer and neutropenia, antibacterial prophylaxis is recommended only for those at intermediate or high risk of infection (e.g., those with prolonged neutropenia >7 days) 1
• For low-risk patients with neutropenia expected to last <7 days (which includes most patients with solid tumors), antibacterial prophylaxis is not recommended 1
• The NCCN Guidelines panel specifically advises that fluoroquinolone prophylaxis should only be considered for patients at intermediate or high risk of infection 1

HIV-Infected Patients

• Antibiotic prophylaxis in HIV-infected patients is recommended only for specific indications:
  • For prevention of recurrent serious bacterial respiratory infections in patients with frequent recurrences 1
  • For Pneumocystis pneumonia prophylaxis in patients with CD4+ counts <200 cells/μL 1
  • For prevention of MAC disease in patients with CD4+ counts <50 cells/μL 1
• Providers should be cautious about using antibiotics solely for preventing bacterial respiratory infections due to the potential for developing drug-resistant microorganisms 1

Potential Harms of Inappropriate Antibiotic Prophylaxis

• Development of antimicrobial resistance 1, 2
• Disruption of the microbiome, which can impair immune responses to viral infections 3
• Risk of Clostridioides difficile infection 1
• Drug toxicities and adverse effects 1, 2
• Increased healthcare costs without clinical benefit 2, 4

Alternative Approaches for Viral Infection Prevention and Management

• Vaccination when available (e.g., influenza, COVID-19) 4
• Good hand hygiene and respiratory etiquette 2
• Symptomatic treatment focusing on hydration, rest, and over-the-counter medications for symptom relief 2
• Point-of-care rapid testing to confirm viral etiology when available 4
• Early antiviral treatment when appropriate and indicated 4

When Antibiotics May Be Considered

• Only when there is clear evidence of bacterial superinfection or coinfection 2
• In specific high-risk immunocompromised populations as defined by guidelines 1
• When recommended by specialty-specific guidelines for particular clinical scenarios 1

In conclusion, current evidence and guidelines strongly advise against the routine use of antibiotics for prophylaxis in viral infections. The focus should be on appropriate symptomatic management, prevention through vaccination when available, and judicious use of antibiotics only when bacterial infection is confirmed or strongly suspected.