What is the recommended treatment for an adult patient with streptococcal (strep) COVID-19 pneumonia, with no severe allergies or contraindications?

Treatment of Streptococcal COVID-19 Pneumonia

For adults with confirmed streptococcal bacterial co-infection or secondary infection in the setting of COVID-19 pneumonia, treat with antibiotics according to standard community-acquired pneumonia (CAP) guidelines: amoxicillin 1g every 8 hours for mild-moderate disease, or a beta-lactam (ceftriaxone or cefotaxime) plus macrolide for severe disease requiring ICU admission. 1

Key Principle: Restrictive Antibiotic Use in COVID-19

The most critical decision point is determining whether bacterial co-infection actually exists, as bacterial co-infection at admission occurs in only 3-8% of COVID-19 patients. 1

• Generally avoid empiric antibiotics in mild-to-moderate COVID-19 pneumonia upon admission, as the vast majority of radiographic findings represent viral pneumonitis alone, not bacterial superinfection. 1
• Bacterial secondary infections occur in approximately 15-20% of hospitalized COVID-19 patients overall, but are concentrated in severely ill patients (up to 50% in non-survivors vs <1% in survivors). 1

When to Start Antibiotics: Specific Clinical Triggers

Start empiric antibiotics immediately in these specific scenarios:

• Severely ill patients requiring ICU admission while awaiting culture results 1
• Immunocompromised patients (chemotherapy, transplant recipients, HIV/AIDS, prolonged corticosteroids) 1
• Radiological findings AND inflammatory markers strongly suggesting bacterial co-infection (high CRP, elevated procalcitonin, lobar consolidation) 1
• Confirmed positive cultures for Streptococcus pneumoniae or other bacterial pathogens 1

Antibiotic Selection for Streptococcal Pneumonia

For Mild-to-Moderate Disease (General Ward)

Amoxicillin 1g orally or IV every 8 hours is the preferred first-line agent for confirmed or highly suspected streptococcal pneumonia in COVID-19 patients. 1, 2

• Amoxicillin provides optimal coverage against Streptococcus pneumoniae and Haemophilus influenzae, the most common bacterial pathogens in COVID-19 co-infection. 1, 2
• The bacterial pathogens in COVID-19 pneumonia are identical to standard CAP pathogens, so standard CAP treatment regimens apply. 1

Alternative for penicillin allergy:

• Azithromycin or doxycycline for non-severe disease 1, 2
• Respiratory fluoroquinolone (levofloxacin or moxifloxacin) 1

For Severe Disease (ICU Admission)

Beta-lactam (ceftriaxone 1-2g IV daily OR cefotaxime 1-2g IV every 8 hours) PLUS macrolide (azithromycin 500mg IV daily) 1

• Alternative: Beta-lactam plus respiratory fluoroquinolone 1
• Do NOT use amoxicillin monotherapy in severe pneumonia requiring ICU care 2

Do NOT Routinely Cover Atypical Pathogens

Avoid empiric coverage for atypical pathogens (Mycoplasma, Chlamydia, Legionella) in COVID-19 patients, as these co-infections are rarely reported. 1

• Perform Legionella urinary antigen testing according to local CAP guidelines, but do not empirically treat unless positive 1

Essential Diagnostic Testing BEFORE Starting Antibiotics

Obtain these tests before initiating antibiotics whenever possible: 1

• Blood cultures (two sets from separate sites)
• Sputum culture (if patient can produce quality specimen)
• Pneumococcal urinary antigen test (highly recommended for all patients)
• Procalcitonin level (to guide antibiotic initiation and duration)

A positive pneumococcal urinary antigen strongly supports bacterial co-infection and justifies antibiotic therapy. 1

Antibiotic De-escalation and Duration

Stop antibiotics at 48 hours if cultures are negative and patient is improving. 1

• If sputum, blood cultures, and urinary antigen tests obtained before antibiotics show no bacterial pathogens after 48 hours of incubation, discontinue antibiotics. 1
• Treatment duration is 5 days for confirmed bacterial co-infection if patient shows clinical improvement (resolution of fever, improved respiratory status, declining inflammatory markers). 1
• Procalcitonin can guide early discontinuation if levels are low or declining. 1

Critical Pitfalls to Avoid

Do not reflexively start antibiotics for every COVID-19 pneumonia patient with infiltrates on chest imaging, as 86% of COVID-19 patients have radiographic abnormalities that represent viral pneumonitis, not bacterial infection. 1

Do not underdose amoxicillin - use high-dose regimens (1g every 8 hours in adults) to overcome intermediate resistance patterns in S. pneumoniae. 2

Do not continue antibiotics beyond 48 hours if cultures are negative unless there is strong ongoing clinical suspicion for bacterial infection despite negative cultures. 1

Do not use azithromycin monotherapy in areas with high pneumococcal macrolide resistance (>25%), as this is common in many regions. 2

Secondary Bacterial Pneumonia (Hospital-Acquired)

For suspected secondary bacterial pneumonia developing during hospitalization (not present on admission):

• Follow local hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) guidelines 1
• Empiric coverage should include S. aureus (including MRSA), Pseudomonas aeruginosa, Enterobacterales, and Acinetobacter based on local resistance patterns 1
• Obtain surveillance cultures to guide targeted therapy 1

COVID-19 Antiviral Therapy

While the question focuses on bacterial treatment, remdesivir (VEKLURY) is indicated for COVID-19 treatment in hospitalized patients, with a 5-day course for those not requiring mechanical ventilation and 10 days for those requiring ventilation/ECMO. 3