Treatment for COVID-19 and Influenza Co-infection
For patients co-infected with COVID-19 and influenza, treat both infections concurrently with oseltamivir or baloxavir for influenza according to standard guidelines, while continuing COVID-19 specific therapies without modification. 1
Diagnostic Approach
- Confirm influenza coinfection using PCR or rapid testing of nasopharyngeal secretions when clinically suspected in any COVID-19 positive patient, as documented coinfection rates range from 0.5-2%. 1
- Obtain comprehensive microbiologic workup including blood cultures, sputum cultures, and pneumococcal urinary antigen testing before initiating any empirical antibiotics. 2
- Direct PCR testing of nasopharyngeal or respiratory secretions is recommended for both pathogens. 2
Antiviral Treatment Strategy
For Influenza Component
- Administer oseltamivir or baloxavir immediately upon confirmation of influenza coinfection, following standard influenza treatment guidelines. 2, 1
- Continue influenza antiviral therapy for the full treatment course regardless of COVID-19 status. 1
For COVID-19 Component
- Non-hospitalized or mild cases: Provide supportive care including rest, nutrition, and fluid support; no immunomodulatory therapy is indicated. 3
- Hospitalized patients requiring supplemental oxygen: Administer systemic corticosteroids, preferably dexamethasone, as this decreases mortality. 2, 3
- Hospitalized patients requiring oxygen, non-invasive ventilation, or mechanical ventilation: Consider combination therapy with glucocorticoids plus tocilizumab, as this reduces disease progression and mortality. 2, 3
- Hospitalized patients requiring oxygen therapy or high-flow oxygen: The combination of glucocorticoids with baricitinib or tofacitinib could be considered as it might decrease disease progression and mortality. 2
Antibiotic Considerations
Do not routinely prescribe antibiotics for COVID-19/influenza coinfection. 2 However, specific circumstances warrant consideration:
- Consider empirical antibiotics only if bacterial superinfection cannot be ruled out, as bacterial coinfection occurs in approximately 40% of viral respiratory infections requiring hospitalization. 1
- Bacterial coinfection upon admission occurs in only 3.5% of COVID-19 patients, while secondary bacterial infections during hospitalization occur in up to 15%. 2
- If antibiotics are initiated empirically, stop antibiotics after 48 hours if representative cultures and urinary antigen tests show no bacterial pathogen involvement. 2
- For confirmed secondary bacterial respiratory infection, follow guideline recommendations for hospital-acquired and ventilator-associated pneumonia treatment. 2
- Limit antibiotic treatment duration to 5 days in patients with suspected bacterial respiratory infection upon improvement of signs, symptoms, and inflammatory markers. 2
Critical Management Pitfalls
- Avoid hydroxychloroquine at any stage of SARS-CoV-2 infection, as it provides no additional benefit and could worsen prognosis, particularly if co-prescribed with azithromycin. 2
- Do not withhold or modify immunosuppressive therapy dosing during influenza prophylaxis if the patient is on bispecific antibodies or other immunomodulatory treatments. 2, 1
- Monitor for drug interactions carefully, particularly in patients on multiple medications for both infections. 1
Isolation and Prevention
- Follow standard isolation protocols for both infections until clinical resolution with RT-PCR clearance. 2, 1
- Influenza vaccination is strongly recommended for all COVID-19 patients and their close contacts to reduce coinfection risk. 2, 1
- A two-dose series of high-dose influenza vaccine, at least one month apart, may increase likelihood of seroprotection in immunocompromised patients. 2