No, antibiotics do not counteract severe covid-19

[Argirios Argiriou]

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17/05/2021 Läkartidningen.

Gunnar Jacobsson, Med Dr, Infection Specialist, Skaraborg Hospital Skövde, Västra Götaland, Sweden.

Early in the covid-19 pandemic, there was uncertainty about the management of sars-cov-2 infection. Different therapies were tried. So do antibiotics. Famous were two French researchers who claimed that azithromycin in combination with hydroxychloroquine reduced mortality [1]. Subsequently, several studies have shown that this is not the case, and the WHO advises against use [2].

Antibiotics were used more in the beginning of the pandemic, partly due to experiences of bacterial co-infections during previous flu pandemics, and partly due to the strong inflammatory onset in covid-19, which could be reminiscent of a bacterial infection. In step with increased knowledge of clinical presentation and therapies, the use decreased, which is well known to clinicians who worked in both primary care and hospital care with covid-19 patients.

In a debate post in Läkartidningen [3], the authors claim that antibiotics can counteract severe covid-19. Although they are aware of the many studies that show that the incidence of bacterial co-infections is low (8.6 percent) [4], they believe that this is due to a lack of bacteriological diagnostics. They are also aware of the initially high use of antibiotics [4] and believe, without referring to any study, that this has saved lives.

The breakthrough for effective treatment is the British Recovery Study [5], which demonstrates the effect of steroids on oxygen-demanding covid-19. Other immunomodulatory therapies have been introduced with concomitant clinical benefits [6]. The authors of the post in LT are not clinicians. However, they have bacteriological knowledge and believe that vaccination with a conjugated pneumococcal vaccine, PCV-13, protects against severe covid-19. This is based on an observational study from California [7] where vaccination (via presumed effect on colonization of pneumococci) with PVC13 gave a lower risk of diagnosis with sars-cov-2.

This is interesting and hypothetical. But the debaters' conclusion is lame. There was no protection against severe covid-19 (hospitalization and / or death): »… that protection arose from the prevention of early stages of COVID-19 pathogenesis rather than prevention of severe post-infection sequelae, which would have led to higher effectiveness estimates against hospitalization and death. This finding is externally consistent with previous studies suggesting a low burden of secondary pneumococcal pneumonia following SARS-CoV-2 infection.

Invasive pneumococcal infections (IPD) have decreased during the pandemic; with 30 percent in the study the debaters refer to [8], where the conclusion is: "The rarity, age and serotype distribution of IPD / COVID-19 coinfections do not support further extension of pneumococcal vaccination."

NICE (National Institute for Health and Care Excellence) in England does not recommend covid-19 antibiotics in its updated guidelines [9]. On the other hand, antibiotics have their place in healthcare-related infections that arise in hospital care, especially intensive care.

It becomes problematic when the debaters finally write that antibiotics should always be considered in "problematic" covid-19 disease in primary care. With the proviso that the authors do not define "problematic", this can lead to worse and riskier outcomes for patients. Covid-19 patients, who typically worsen 5-10 days after the onset of symptoms, should not be prescribed antibiotics but should be referred to hospital for evaluation of oxygen demand and steroid therapy.

REFERENSES
 
1) Gautret P, Lagier JC, Parola P, et al. Clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 COVID-19 patients with at least a six-day follow up: a pilot observational study. Travel Med Infect Dis. 2020;34:101663.

2) COVID-19 Clinical management. Living guidance. 25 January 2021. Geneva: World Health Organization; 2021. WHO/2019-nCoV/clinical/2021.1.

3) Burman LG, Schalén C. Pneumokockvaccination eller antibiotika motverkar svår covid-19. Läkartidningen. 6 maj 2021.

4) Langford BJ, So M, Raybardhan S, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect. 2021;27(4):520-31.

5) The RECOVERY Collaborative Group; Horby P, Lim WS, Emberson JR, et al. Dexamethasone in hospitalized patients with covid-19. N Engl J Med. 2021;384( 8 ):693-704.

6) Gordon AC, Mouncey PR, Al-Beidh F, et al. Interleukin-6 receptor antagonists in critically ill patients with covid-19. N Engl J Med. Epub 5 feb 2021. doi: 10.1056/NEJMoa21004332020.

7) Lewnard JA, Bruxvoort KJ, Fischer H, et al. Prevention of COVID-19 among older adults receiving pneumococcal conjugate vaccine suggests interactions between Streptococcus pneumoniae and SARS-CoV-2 in the respiratory tract. J Infect Dis. Epub 9 mar 2021. doi: 10.1093/infdis/jiab128.

8 ) Amin-Chowdhury Z, Aiano F, Mensah A, et al. Impact of the coronavirus disease 2019 (COVID-19) pandemic on invasive pneumococcal disease and risk of pneumococcal coinfection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): prospective national cohort study, England. Clin Infect Dis. 2021;72(5):e65-75.

9) National Centre for Health and Care Excellence. COVID-19 rapid guideline: managing COVID-19 NICE guideline [NG191]. 23 mar 2021 [uppdaterat 8 apr 2021]. Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος