Should We Prescribe Antibiotics in Older Patients Presenting COVID-19 Pneumonia?

To the Editor:

The COVID-19 pandemic is responsible for a particularly high level of morbidity in the older population. Most deaths are the result of severe viral pneumonia, for which therapeutic management is still a matter of debate. Corticosteroids are to date the only therapeutic class that has proven benefit in terms of mortality in hypoxemic SARS-CoV-2 pneumonia, whereas the benefit of tocilizumab remains unclear. However, such therapeutics are associated with increased risk of bacterial infection, especially among older individuals. Moreover, the distinction between bacterial and viral pneumonia is particularly difficult, and coinfections have been highlighted, although in limited proportions.4, 5, 6 There is currently no distinctive tool to conclusively distinguish SARS-CoV-2 pneumonia from viral-bacterial coinfections, and atypical symptoms are particularly frequent in older patients. Recent guidelines suggest a restrictive use of antibacterial drugs in patients with COVID-19. , However, the level of evidence for such recommendations is very low, and antibiotics are widely prescribed in practice, , especially in older patients.

To our knowledge, whether systemic antibiotic therapy should be prescribed in acute pneumonia patients testing positive for COVID-19 has not been evaluated yet in a geriatric setting. In a multicenter retrospective cohort study of older patients with a SARS-CoV-2 pneumonia, we sought to assess whether the use of antibiotics was associated with lower mortality.

We included 124 consecutive patients aged ≥75 years hospitalized from March 1 to May 1, 2020, in 4 hospitals of one of the French regions most affected by the first wave of COVID-19. Patients had radiology-proven pneumonia and tested positive for SARS-CoV-2 (Real-Time Polymerase Chain Reaction Novodiag; Movidiag, Espoo, Finland). We compared mortality 1 month after admission between patients with and without antibiotic treatment (Supplementary Material).

Pneumonia was defined according to the American guidelines, in the acute presence of (1) 2 or more of the following signs: new cough, sputum production, dyspnea, pleuritic pain, abnormal temperature (<35.6°C or >37.8°C), or altered breathing sounds on auscultation and (2) a new infiltrate on chest imaging.

Of the 124 patients with pneumonia, 102 (82%) received antibiotics and 22 received none. The 2 groups were similar in terms of sex (male 52% vs 48%, P = .9), age [median age (interquartile range): 85 (81-89) vs 86 (83-90), P = .4] and comorbidities [median Charlson Comorbidity Index: 2 (1-4) vs 3 (2-4), P = .2). However, patients with antibiotics had more severe presentation (severe or critical pneumonia according to WHO criteria: 49% vs 23%, P = .02). Alveolar condensation was identified on the CT scan in 38% and 27%, respectively (P =.3). The antibiotic regimens included third-generation cephalosporins (3GC) (75 patients), macrolides (50 patients), penicillin + beta-lactamase inhibitor (40 patients), and fluoroquinolones (9 patients). Antibiotic associations were frequent, especially 3GC with macrolides (45 patients).

As shown in Figure 1 , mortality rates did not significantly differ between the 2 groups at 1 month (36% of death in both groups; P > .99). After adjustment on WHO severity classes, Charlson Comorbidity Index, age, sex, and mortality did not significantly differ in the 2 groups [adjusted hazard ratio (95% confidence interval) = 0.88 (0.40-1.92), P = .7]. Median duration of hospital stay did not significantly differ between the 2 groups [11 (7-16) vs 10 (7-19) days, P = .8]. Bacteremia during hospitalization was rare in both groups (5% vs 4%, P = .9). One case of Clostridioides difficile colitis was diagnosed in the antibiotics group.

Fig. 1

One-month survival after admission for SARS-CoV-2 pneumonia in older patients with or without antibiotics.

In this observational study in older comorbid inpatients presenting severe forms of COVID-19, 1-month mortality was very high (nearly a third of patients) and did not appear to widely differ under antibiotic treatment. If confirmed, these preliminary results from a relatively small cohort of older inpatients with severe SARS-CoV-2 pneumonia suggest that the use of antimicrobial drugs should be restricted.