The use of antibacterial agents in patients with COVID-19 is controversial and requires compelling evidence to avoid excessive and unnecessary prescribing. Clinical presentation seems to be the first and most convincing option in making the decision to initiate antibiotic therapy, and laboratory (leukocytosis, ESR, lymphopenia, C-reactive protein, procalcitonin) and radiological data can facilitate the decision-making process through appropriate and meticulous monitoring. Beta-lactams (penicillins, cephalosporins), including extended-spectrum ones, macrolides, and fluoroquinolones, can be considered first-line agents in moderately to severely ill patients admitted to intensive care units. The duration of SARS-CoV-2 infection from symptom onset to hospitalization may be crucial for initiating antibacterial treatment in the context of detecting the onset of cytokine storm, which may require the use of corticosteroids.
Strategies for the use of antimicrobial agents in SARS-CoV-2 infection have been evaluated during the pandemic, with significant controversies based on the COVID-19 period, regions, and accumulated experience. In the early phase of the coronavirus pandemic, most national and international guidelines on COVID-19 management recommended that empirical antibiotic treatment be considered for all critically ill COVID-19 patients, based on previous data from severe influenza A infection. Antibiotics have reasonable roles in managing COVID-19, particularly for suspected or confirmed bacterial co-infections. The World Health Organization has recommended avoiding antibiotics for the treatment of COVID-19 unless bacterial co-infections are present. However, growing evidence suggests that a significant proportion of patients with COVID-19 are unnecessarily treated with antibiotics. Empirical antibiotic prescribing rates ranged from 70% to 98% of patients, despite low rates of confirmed secondary bacterial infections (7-19%).