Antibiotics

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  • COVID-19 is a viral illness caused by the SARS-CoV2 coronavirus.
  • In the majority of patients with COVID-19 bacterial super infection is uncommon.
  • Antibiotics are not routinely required. 
  • CRP should not be used as an indicator of bacterial super infection in patients with severe COVID-19 infection.

Antibiotics are not required...

CXR - bilateral consolidation/ground glass change

AND

Bloods - lymphopenia without neutrophilia

AND

Symptoms - dry cough, clear sputum

This is typically early in the course of the illness.

Consider antibiotics...

CXR - unilateral consolidation

AND

Bloods - neutrophilia

AND

Symptoms - purulent sputum

Often after 10 days of symptoms starting 

Antibiotic recommendations

Duration = 5 days total (IV and oral)

Amoxicillin 500mg every 8 hours orally

OR

Doxycycline 200mg stat dose followed by 100mg daily for a further 4 days orally.

If the patient meets severity criteria using CURB-65 of 3 or more, or qSOFA 2 or more then consider:

Co-amoxiclav 1.2g every 8 hours IV if admission with the last 48 hours

Avoid co-amoxiclav in patients >65 years old, with previous C.diff infection or with risk factors for C.diff infection.

In the Frail Elderly follow the guidance for Severe pneumonia in the frail elderly.

OR

Follow guidance for Hospital acquired pneumonia.

Atypical organisms are unlikely with COVID-19 - clarithromycin is not required.

If patient deteriorating (based on escalating NEWS ≥5, qSOFA , see Sepsis 6)

  • Send blood and sputum for culture.
  • Escalating oxygen requirement and fever are not always sign of secondary bacterial infection.
  • If currently on antibiotics escalate to Hospital Acquired Pneumonia guidance.
  • If deteriorating in critical care discuss with microbiology and review VAP guidance.
  • Consider sending sputum and blood samples for fungal testing particularly for patients getting worse whilst in critical care.

 Notes

  • Where the ECG is abnormal, or pre-disposition to QT interval prolongation, or ECG can not be performed, avoid the use of Clarithromycin. Additional cover for Atypical pneumonias is not required routinely for patients with COVID-19 even where there is a possibility of bacterial secondary infection.
  • Clarithromycin is associated with QT prolongation and cardiac arrhythmia.
  • There is some evidence of myocardial damage in patients with COVID-19.

Review and revise @48 hours

Review and stop or justify continue:

  • Where antibiotics are initiated @48-72 hours review need for ongoing antibiotics.
  • If no evidence of bacterial infection and no positive microbiology investigations STOP antibiotics
  • If antibiotics are to be continued document a hard stop for oral antibiotics and conitnue daily review of the need for IV antibiotics.