Version 1: 19-03-2020

Initial empiric antibiotics

  • COVID-19 itself is not an indication for antibiotics.

  • There may be concerns regarding superimposed bacterial pneumonia.  

    • If in doubt, obtain bacterial cultures and procalcitonin, prior to initiation of empiric antibiotic therapy. 

    • Based on results, antibiotics may be discontinued in <48 hours if there isn't evidence of a bacterial infection (this is exactly the same management as influenza pneumonia).

Delayed bacterial superinfection [1]

·       Bacterial pneumonia can emerge during the hospital course (especially ventilator-associated pneumonia in patients who are intubated).

·       Among patients who died from COVID-19, one series found that 11/68 (16%) had secondary infections [2].

·       This may be investigated and treated similarly to other ventilator-associated pneumonias, or hospital-acquired pneumonias.


Empiric antimicrobials should be given to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour of initial assessment for patients with sepsis. [3]

  • Remark 1: Although the patient may be suspected to have COVID-19, administer appropriate empiric antimicrobials within 1 hour of identification of sepsis [4]. Empiric antibiotic treatment should be based on the clinical diagnosis (community-acquired pneumonia, health care-associated pneumonia [if infection was acquired in health care setting] or sepsis), local epidemiology and susceptibility data, and national treatment guidelines. 

  • Remark 2: When there is ongoing local circulation of seasonal influenza, empiric therapy with a neuraminidase inhibitor should be considered for the treatment for patients with influenza or at risk for severe disease [4]. 

Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.


(1) Josh Farkas. COVID-19. The Internet Book of Critical Care.

(2) Ruan, Q., Yang, K., Wang, W. et al. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med (2020).

(3) World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID19 disease is suspected. Geneva: World Health Organization; 2020 (accessed 16 March 2020). 

(4) Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43(3):304-77. Epub 2017/01/20. doi: 10.1007/s00134-017-4683-6. PubMed PMID: 28101605.

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