Guidelines to Reduce Empiric Antibiotic Therapy Among Inpatients With COVID-19

Worried African American woman sitting at home while being sick
Investigators conducted a quasi-experimental, retrospective study of adult patients with COVID-19 pneumonia to evaluate antibiotic use for community-acquired bacterial pneumonia following the release of guidelines.

An observable drop in duration of antibiotic therapy occurred after implementing recommendations from a new guideline on initiating and discontinuing antibiotics for community-acquired bacterial pneumonia among COVID-19 inpatients. The results of this study were published in BMC Infectious Diseases.

In a quasi-experimental, retrospective study of adult patients with COVID-19 pneumonia initiating empiric antibiotic treatment for community-acquired bacterial pneumonia, duration of therapy before and after guideline implementation was evaluated. Clinical outcomes such as mortality, hospital readmissions, and hospital length of stay were also assessed.

Of 506 patients screened for inclusion, 102 patients were included preintervention and 404 patients were included postintervention. The proportion of patients receiving antibiotics was significantly lower postintervention at 170 of 404 (42%) compared with 76 of 102 (74.5%; P <.001). In the postintervention group, antibiotic treatment was initiated in more patients according to criteria consistent with the guideline (148 patients [87%] compared with 52 patients [68%]; P =.001). There were also significant reductions in the numbers of patients prescribed azithromycin (P <.001), ceftriaxone (P =.005), and cefdinir (P =.001) postintervention.

The median duration of antibiotic therapy and the duration of atypical antibiotic coverage were shorter postintervention at 1.3 days shorter (2.3 vs 1 day, P <.001) and 2.8 days (3.8 vs 1 day, P <.001), respectively. Between the groups there were no differences in Clostridioides difficile infections, the need for antibiotic re-initiation, all-cause hospital readmission rate, mortality rate, or hospital length of stay.

Due to the quasi-experimental nature of the study, several confounders may have contributed to the results, including higher rates of mechanical ventilation in the preintervention group and more patients having fever and leukocytosis in the postintervention group.  Also, over time clinical comfort in managing COVID-19 at this center likely improved, and changes to SARS-CoV-2 testing may have reduced turnaround time during the postintervention period. The study was also underpowered and not designed to investigate clinical outcomes. The researchers also noted that although developing a guideline is a simple intervention, daily reinforcement is potentially more difficult. Therefore, the results may not be generalizable to centers lacking the resources to provide daily review.

The researchers did conclude that the targeted clinical guideline was “an effective tool to reduce inappropriate prescribing of antibiotics for [community-acquired bacterial pneumonia]” in this patient population, adding that further work is needed to explore the clinical impacts of such an intervention.


Pettit NN, Nguyen CT, Lew AK, et al. Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission. BMC Infect Dis. 2021;21(1):516. doi:10.1186/s12879-021-06219-z