How are in principle and in practice the covid-19 patients, who are at risk, treated during the stages of their disease, from the minimal symptoms, respiratory symptoms, respiratory insufficiency end eventual in their terminal stages.
Do we have the precise information about the development of the symptoms of the covid-19 in Italian patients and what is the precise therapy that they receive at different stages? I mean from the (1) first symptoms, (2) appearance of the respiratory signs and (3) the further therapy, including in (4) the ICU and before their eventual death. In particular what they receive as the first therapy, and what is the routine therapy recommendation and practice all way down to their dismissal or death in the ICU.
Patients with viral pneumonia can develop a secondary bacterial infection that may need to be treated with an antibiotic, although, this complication is reported to be uncommon early on in the course of COVID-19 pneumonia.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
Therefore: do they (the patients >65 years old with some slight respiratory or other adjacent diseases) - do they receive systematically, in addition to other therapy, the antibiotics as the prevention of superimposed bacterial infection, when, before or after they would develop respiratory insufficiency?
AGAIN. Does the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial complications!!!
It appears that in France they in principle, do not get any antibiotic. Did the patients who died in Italy, had, at the earlier stages, the antibiotics?
Article Acquired Long QT Syndrome: A Review of the Literature
This review discusses some of the points I outline below.
Co-infection with other viruses and bacteria has been demonstrated for Covid-19 and MERS. So several antibiotic medications are recommended for the treatment of Covid-19.
However many medications have been recommended for the treatment of Covid-19 are associated with prolongation of the QTc interval and therefore torsade de pointes and sudden cardiac death.
The evidence of the potential benefit of chloroquine and hydroxychloroquine in the treatment of Covid-19 is increasing.
Other medications which may be used in this cohort include the macrolide antibiotics (e.g. azithromycin). These can also prolong the QTc interval. Administering several medications that may prolong the QT interval is associated with a high risk of complications.
In medicine risks and benefits must be balanced. Safety netting is important whenever there is a great potential benefit but also a very significant risk. In that context QTc intervals, renal and liver function must be monitored closely in patients treated with chloroquine and or macrolides. They should probably not be started if the baseline QTc is more than 450 ms. It should probably be stopped if the QTc increases 25% above baseline. It should definitely be stopped if QTc is above 500 ms. This is an evolving situation and recommendations may change as the potential risks and benefits become clearer.
Beta-blockade is used in the treatment of congenital and acquired long QT syndrome, so may be beneficial in this setting.
But more precisely:
Did the Italian patients who died (particularly older ones) receive early "preventive" antibiotic therapy against bacterial co-infection? Could it be that they died of bacterial superinfection?
Do we have these statistics?
Interesting. But they do not state any other therapy apart from hydroxychloroquin. The Marseille study used in addition azitromycin.
Again, my question is: did the Italian patient or other patients die sometimes because they develop bacterial superinfection? And they ware not offered antibiotics...
Please see this article when considering treatment for Covid-19
Ventricular Arrhythmia Risk Due to Hydroxychloroquine-Azithromycin Treatment For COVID-19
https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-risk-due-to-hydroxychloroquine-azithromycin-treatment-for-covid-19
Please take a look at this useful link
https://www.thelancet.com/action/showPdf?pii=S1473-3099%2820%2930152-3
AGAIN:
Did the patients that died had on the forth- fifth-day preventive antibiotics? Does anybody have this data?
yes, pls see following useful article
https://gulfnews.com/world/europe/coronavirus-anti-malaria-drug-plus-antibiotic-may-offer-relief-1.1584769653854
What to do if you get Covid-19.
These recommendations apply to young adults with no medical conditions. If you have medical conditions or any concerns it is best to speak to your doctor for specific advice. This is particularly important if you have a pre-existing lung condition or are taking immunosuppressant medications.
Prepare for a nasty chest infection.
Things you have to hand
• face tissues,
• Acetaminophen; for a fever over 38°c, take acetaminophen rather than Ibuprofen.
• Generic, cough medicine to thin mucus (check the label make sure that it does not contain paracetamol; otherwise you could double dose and get side effects)
• vaporub for your chest is also a great suggestion.
• humidifier would be useful; however, turning on a hot shower and breathing in the steam in the bathroom may also help.
• Food: soups are ideal
• Drink: stay well hydrated, water is fine
Prevent transmission
• Rest and do not leave your house. You could be infectious for fourteen days.
Avoid elderly people and those with pre-existing health conditions.
• Wear gloves and a mask to avoid transmitting the infection
• If you do not live alone. Isolate yourself in your bedroom. Ask those you live with to leave things outside to avoid contact.
• Wash your bed linen and clothes frequently. sanitise your bathroom.
The vast majority of Covid-19 cases in healthy adults can manage at home with rest, hydration, acetaminophen, cough medicine.
Go to hospital if you are having trouble breathing or your fever is very high (over 39°C) and not settling with acetaminophen and cooling with ice packs or if you are worried, in distress or feel your symptoms are getting worse.
If you have any medical conditions please seek specialist advice from your doctor.
Azm Shaher
I am in Paris and know so well the Marseille protocol. No, my question concerns more the Italian sample of 2-3.000 patients, in fact all more then 75 or 80 years old dead patients: did they receive antibiotics?
Raykumar
So no antibiotics? You presume that there is certainly no superinfection with bacteria? Even in 75 years old COPD?
Is this so?
I would like to see the correlations between antibiotic or not on the 5-6 day of coronavirus infection and the outcome. Particularly in Itali.
Did the patients who died from COVID-19 pneumonia, have antibiotics from the start?
You can see in this paper that half of non-survivors experienced a secondary infection: https://www.sciencedirect.com/science/article/pii/S0140673620305663
SECONDARY INFECTION MEANS BACTERIAL INFECTION THAT IS most often SENSITIVE TO ANTIBIOTICS: In France, Covid-19 patients that are at risk, do not receive antibiotics FROM THE START! Is this an assassination of the patients? In other words, the patients who are at risk, COPD, old, with co-morbidity, should have preventive antibiotic, as the patients of Prof Raoult in Marseille had. (with hydroxychloroquine or not). Did the patients who died from COVID-19 pneumonia have antibiotics from the start?
Does the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial complications!!!
On March 29, 2020, I asked and I am asking AGAIN:
Does the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial complications!!!
https://labblog.uofmhealth.org/rounds/too-many-covid-19-patients-get-unneeded-just-case-antibiotics
https://academic.oup.com/jacamr/article/2/3/dlaa051/5872562
I add now more questions:
How many patients died up to now just because the antibiotics were NOT GIVEN?
How many COVID-19 patients die from bacterial superinfection coupled with the late administration of antibiotics?
Do we have some evidence about this?
@ Dragan Pavlovic Does the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial complications!!!
The question calls for a categoric/elaborate meticulously designed clinical trial to conclusively segregate the impact of varying stages of administering antibiotics to the critical COVID patients. In the absence of any systematic information about this deadly virus, the top priority world over has been to save the patient from its fatal grips. As such, in most cases the treatment must have been by and large symptomatic. It is highly unlikely that any of the hospitals or even the researchers might have indulged in subjecting the already suffering / scared patients to unpredictable combinations of various experimental medicines/therapies.
@ Dragan PavlovicDoes the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial complications!!!
One of the Clinical Management Protocol for COVID-19 says:
Antibiotics should not be prescribed routinely unless there is clinical suspicion of a bacterial infection.
If 50% of the patients that died of Covid-19 have bacterial superinfection, then maybe we should think about the antibiotics earlier?
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext
@ Dragan Pavlovic
Death is the end point. The recommendation suggests that antibiotic should not be prescribed routinely before initiation of bacterial infection. Hence the stage of initiation of bacterial infection, if any, should be ascertained before resorting to antibiotics. Yes, if antibiotics are not prescribed even after bacterial infection, that might lead to the fatal consequences.
Shankar
Fine, we are getting closer.
Who are the people who developed a bacterial infection – and there are more than 50% ?
The fact is that the patients on the ventilator all have some positive culture of sputum for which, we do not know the certain meaning. If there is some inflammation that is localized in the lungs, we presume bacterial or Aspergillus or similar fungal infection. This is very hard to determine.
What do we do preventively? Antibiotics if there are bacteria in sputum? And there are there almost always. So antibiotics anyway in a COPD patients with Covid-19??
The real problem is that the people who did not give antibiotics preventively to the patients at risk, who then died of the bacterial infection (in some studies 50% od patients that died had a bacterial infection!) - will never respond spontaneously.
Thank you Dragan, an extremely important question.
I think that much more can be done early on in COVID 19 infection by further repurposing existing drugs.
It is excellent news about a vaccine against COVID 19 but until this is fully implemented in the global population there may be a drug to mitigate the severity of COVID 19 complications.
There is some evidence and conceptual thinking in immunology about the benefit of reducing mast cell expression of histamine and thus reducing the severity of COVID 19 symptoms by administering antihistamine drugs when early symptoms of a SARSCoV-2 infection are observed and a positive test for the virus infection. Antihistamines are readily available without prescription and like dexamethasone for severe symptoms, may reduce severity of some COVID 19 symptoms and reduce the need hospital admissions in some patients, particularly progression to alveolar inflammation. Should we add this suggestion to the advice about vitamin D replacement?
Resident mast cells are activated during COVID 19 infection and release histamine, which is important in the inflammatory symptoms observed.
Although mast cell activation and release of chemicals, including histamine, is important to the cytokine driven T-cell differentiation as the adaptive response, expression of histamine can disrupt the homeostasis of the immune system and play an important role in the development of COVID-19 pneumonia, contributing to some of the severe symptoms of alveolar inflammation.
A centre in France has already tried this concept on a group of patients who were positive for COVID 19, with significant success.
Just as Dexamethasone has been repurposed as anti-inflammatory medication for severe COVID 19 symptoms perhaps ‘off the self’ antihistamines could be taken for early symptoms.
As an example, there are no officially approved drugs or vaccine to treat dengue disease, MC stabilisation can be achieved with the antihistamine drug ketotifen reversed many of the responses due to MC activation, including reducing the effects of histamine.
If this treatment regimen proves to be successful in some patients, this would be of great advantage in reducing the severity of the pandemic and reduce the need for hospitalisation.
As most patients in the UK, who have symptoms or test positive do not see a doctor but are encouraged to phone 111 for advise (Paracetamol or NSAIDS) or to ask for an ambulance with breathing difficulties. Should patients be advised to trial this antihistamine regimen? Like the public information about vitamin D, should everyone be advised to try this?
How this would effect bacterial oportnistic infections is another question.
How can we test this hypothesis using existing products (Loratadine, Cetirizine)?
How can we test this?
No guys, to recommend is not enough.
Late antibiotics are given very often, and this is often just too, too late. No.
You should look up the data in your hospitals. Make the correlation between letal outcomes vs. survivals and early antibiotics vs. late antibiotics in compromised patients. Did the early antibiotics correlate with more survival as compared with late or no antibiotics?
I think that we are definitely missing many opportunities for prophylaxis taken early on in infection of COVID 19. In the UK COVID 19 positive patients do not see a doctor unless they have breathing difficulties and this is too late!
I have to call your attantion to this article AGAIN:
https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930566-3
What do you say?
To reduce the secondary infection particularly in case of pneumonia or severe infection antibiotics may used with Remdesivir like potent antiviral - https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30444-7/fulltext
Jaydip,
Right.
I do not really understand what, in this article, the connection is between preventing pneumonia in compromised patients and saving their lives and potential (possible?) antibiotic resistance in 2050 !?
I asked the question on March 29th 2020. No real answer was given and the antibiotics were NOT GIVEN to a number of the patients that were at risk of bacterial superinfection. Thousands of patients.
I agree with Dr Pavlovic! Covid-19 is not the unique cause of pneumonias! Many viruses and bacterias (protozoa., fungi) are between causes of pneumonia! Antibiotics are the only etiological (causal) therapy!!!
Most patients see a doctor when they have acute symptoms. At this time the effect of drugs is less
My suggestion would be that patients testing positive for COVID 19 would be advised to take antihistamine (unless otherwise contraindicated previously by clinician), patients may already have started to have symptoms before diagnosis so to take the over the counter (OTC) medication, when testing positive for COVID 19 or the onset of symptoms, whichever came first. Patients contacting the 111-phone UK service could be advised to take an OTC antihistamine along with the other advice already given to take Paracetamol and vitamin D.
My suggestion is that households be advised to have the OTC antihistamines in their homes in case of a positive diagnosis. I do not suggest that the medication would inhibit infection at all but just would reduce the severity of some of the symptoms caused by the action of histamine, such as, dyspnoea and hypoxia in some patients.
Viral load will probably not be affected by this therapy so this would have to be monitored. The dosage of the normal daily dose may need to be greater than that stated on the packets. Severe allergic reactions sometimes require four tablets (one a day) to be taken as the maximum dose.
The official advice from the NHS Specialist Pharmacy Service says that hay fever sufferers are safe to take antihistamine products, if infected with the virus. All OTC or non-prescription drugs refer to medicine that you can buy without a prescription. They are safe and effective when you follow the directions on the label or as directed by your health care professional.
The concept does seem far too simplistic to be helpful but the immunology theory does hold up as worth a try.
@Dragan Pavlovic.
I agree with you on the antibiotics.You are right. Antibiotics should be added to the treatment protocols of COVID-19 patients.
Best Regards
In my part of the world, antibiotics are available otc
So all patients appraching to our hospital in mod or severe covid have almost always taken antibiotics courses.
Personally i feel covid is not enough for prophylactic antibiotics as most infections are mild and recover, but in mod to severe covid on steroids and immunosuppressive, antibiotic cover may be appropriate
Karthikeyan
”Regulated” ? How? We seldom “wait” for a lab determination of the bacterial infection. So, for example, if I think that my patient has a bacterial infection, I can prescribe it.
It was recommended giving an empiric therapy to COVID-19 patients to prevent secondary infection. To date available evidence supports restrictive antibiotic use.
Mohammad
Sorry, RESTRICTIVE? Just like this?
I was asking for evidence and the retrospective data on the correlation of mortality and bacterial superinfection/antibiotics use in the risk population.
I were also want to know this answer, currently the data rarely unknown.
Message from Astrobiology: first global foci are linked geographically.
We have answer why.
Alexander,
the question was about the antibiotics, the patients at risk snd covid-19. Not about unjustified hypotheses - which number is INFINIT. So I am curious what are justifications for the hypothesis proposed above?
You are right. My answer is wider than the question. And your cold scientific fine brain could mark pattern of 3 huge layers of data which match: statistic, geographic and genetic. Which cut the number of infinite hypotheses to actually one. This one I've illustrated above.
3 Peer-reviewed articles are in my profile. Pls check.
It's not just another hypothesis. It's the only one model which describes pandemic with precise accuracy.
Alexander,
You vere very kind to write on this thread. However your answer is not "wider than the question" asked, but is simply unrelated. Please address this question on a separate thread. Thanks very much indeed.
(By the way, I read the Hoyle and Chandra's book in 1983. I thought that it was fascinating. However, I thought that it subscribes to the theory of "The Effects of Everything on Everything". A theory that is simply, even if conditionally true, either useless or even just false.)
Hello,
I think that the use of antibiotics in SARS-CoV-2 patients is justified with the following reasons (listed not by the importance, since all are equally important):
1. Prophylactic of secondary bacterial infection. Damaged lung tissue, with local ischemia and hypoxia, and lots of dead cells - is a good substrate for a secondary bacterial infection.
2. Non specific interactions of antibiotics with immunoglobulins and viral proteins. Since antibodies that are produced in response to RBD of S protein can be compared with "chemical magnets" because of its pretty much low specificity - it is able to interact with the wide range of molecules, especially comparatively small molecules. Same apply to the RBD itself - it can have non specific interactions with small molecules including antibiotics. So with a meaningful concentration of said molecules the therapeutic antiviral and immunomoprotective effect may be induced. By the way using of anti coagulants like Heparin in SARS-CoV-2 patients also may be justified by this non specific interactions.
3. Immunosupressive action of antibiotics. SARS-CoV-2 infection includes abnormal immune response, immunosupressive drugs use targeting this response and antibiotics have some non specific immunosupressive activity.
Cons and solutions:
Since antibiotics kills symbiotic and natural bacteria in humans that are deeply involved in immunomodulation, the use of antibiotics should be practiced with the extensive use of probiotics on every stage of the antibiotics treatment.
secondary bacterial infection can be a problem. can be guided by pro-calcitonin, which is current local practice.
Avinash
For all bacterial superinfections? Does increased PCT mean bacterial superinfection??? Do you have a reference paper for this?
Try this paper Dragan,
Int J Appl Basic Med Res. 2013 Jul-Dec; 3(2): 77–83.doi: 10.4103/2229-516X.117051PMCID: PMC3783672PMID: 24083140
A novel marker procalcitonin may help stem the antibiotic overuse in emergency setting
T Mahajan and Aparna Tanwar
I have demonstrated with Michael Dommasch and other colleagues that PCT may involve NO pathway and that it is by itself significant for the symptoms probably in sepsis. However, as a prognostic sign, it is not specific.
Incubation of rat aortal rings with procalcitonin (PCT) partially inhibits sodium nitroprusside induced relaxation in vitro. January 2008, Conference: Eur J Anaesth, 25(44): 165, https://nbn-resolving.org/urn:nbn:de:gbv:9-000959-5
Procalcitonin is often used to de-escalate antibiotics as per guidelines. In my country, due to popular beliefs and the easy availability of antibiotics- most patients have already taken azithromycin, doxycycline, etc before the presentation. In hospitalized patients of COVID-19 in the ward, we don't give any antibiotics. However, once the patient is shifted to ICU, he/she is invariably on a cocktail of antibiotics
Dear Pranav,
What do you think how many of these patients get orthostatic pneumonia (bacterial or fungal)?
if you father were admitted in your ward, would you not give him antibiotics? When you know that being in bed, having inflamed airways, bacterial and fungal infections are almost certain?
https://www.researchgate.net/post/How_to_recover_from_COVID-19_virus_within_48_hours
Sabry,
the point of my question is in the really BAD policy of administration of antibiotics during the Covid-19 epidemics, blind restriction of its use and on the other hand unjustified massive use that has been followed by bacterial selection or fungal superinfection in many patients.. The result was that many of patients at risk did not receive them and died from bacterial superinfection while those that received them when they should not, or received them often for too long, suffered from the concomitant nosocomial infections.
This was my hypothesis. I wanted to see whether this has been supported by larger studies.
https://www.researchgate.net/post/Antibiotics_in_COVID-19_are_they_really_helping_us_or_harming_us_Need_to_re-think
Prashant,
I have never heard of any school of medicine where the use not only of antibiotics but of any agent is advised blindly to anybody presenting a set of symptoms or some approximate diagnostics. Or, maybe, there are such circumstances, like that all travellers going to India get a cocktail of 3-4 vaccines or antimalaria agents... But still, the question is one other.
On the contrary, there is a blind recommendation that the antibiotics should NOT BE USED for any viral infections if some additional indications are not present.
My question is whether this advice was falsely interpreted as a blind ban of the antibiotics that produced then very high mortality in the groups that were not considered with more attention and that SHOULD HAVE HAD antibiotics.
Some evidence shows that more than 50% of the ICU patients that died had a pulmonary bacterial superinfection. I witnessed that many patients, that had chronic obstructive pulmonary disease (COPD) often did NOT get antibiotics preventively. On the other hand, the reports of fungal superinfections are very high so the undesirable effects may be also the problem. It is certainly very frequent that the aggressively ventilated patients often have all those infections and it is hard to distinguish the causal chain.
Still, my question was and is whether the routine order in the form “viral infection should not be treated with antibiotics” produced a disaster during the Cvid-19 pandemic.
Mild COVID-19 cases seen as outpatient do not benefit from Azithromycin
Please have a look at this article in JAMA:
Article Effect of Oral Azithromycin vs Placebo on COVID-19 Symptoms ...
COVID-19 is caused by a viral infection. There is no benefit of treatment with antibiotics unless there is a bacterial co-infection. Blind antibiotic therapy predisposes to the development of antibiotic resistance.
However, it is difficult to identify bacterial co-infection in the patients with COVID-19 as the symptoms are similar. So I am aware that many clinicians are still using blind antibiotic therapy in all patients presenting to hospital following SARS-CoV-2 infection.
The most fatal effect of Covid19 - After second wave the antibiotics becoming ineffective ie more and more resistant - https://www.researchgate.net/post/What_is_antibiotic_resistance-causes_effects
Serious problems created by overuse or inappropriate antibiotics
Overuse and inappropriate of antibiotics, or steroids in patients who don not need them is one of the reason of these complications in COVID-19 patients:
1. Multi-Drug Resistant (MDR) bacteria e.g. Pseudomonas, ESBL E.coli or Proteus
2. Fungal infections like Candida auris (white fungus), or Mucormycosis (Black fungus)
Antibiotics are often not needed in treatment of patients with COVID-19
This has been the finding of a study in the UK.
Please have a look at this link:
Article Antibiotic Use in UK's COVID-19 Patients Often Unnecessary
In Iraq, according to my knowledge, azithro-myosin is used, and according to the progress of the case, ceftriaxone is used
Antibiotics do not work against viruses; they only work on bacterial infections. Antibiotics do not prevent or treat COVID-19, because COVID-19 is caused by a virus, not bacteria. Some patients with COVID-19 may also develop a bacterial infection, such as pneumonia.
https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/covid-19-frequently-asked-questions
Thanks, Chuck,
But this was not the question.
Please red my introduction to the discussion.
Also see the following useful link for better insights.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785281/
https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-021-00344-w
Not to give coronavirus patients antibiotics when treating them at home, stressing that antibiotics are not given to treat the virus, but antibiotics must be given in the hospital when there is a bacterial infection associated with infection with the virus.
Thanks, Malik.
You are saying that "8% of them had a bacterial coinfection".
Could you give us that full reference, please?
Thanks very much indeed.
A recent study reports:
A total of 18.5% of 64,961 COVID-19 patients (n = 12,040) presented with bacterial infection at admission, 3.8% (n = 2,506) developed secondary infection after admission, and 0.9% (n = 574) had both. However about 50% of the patients over 70 years of age presented with or had bacterial infection following admission.
Jonathan D. Baghdadi et al., Antimicrobial Agents and Chemotherapy, Vol. 65, No. 11, 2021 (18 October 2021).
We may add to this that pneumonia of not determined origin (fungal, other viral) may complicate the interpretation.
I came across the same study referred to by S J Malik . The reference is:
Article Antibiotic Use in UK's COVID-19 Patients Often Unnecessary
Generally azithromycin , doxicyclin used at the early stage of Covid19 pateints becoming resistant - https://www.researchgate.net/post/What_is_antibiotic_resistance-causes_effects
TO ALL
I must repeat the most important from my question since many of you too often discusse just more general use of antibiotics:
Do they (the patients >65 years old with some chronic respiratory or other adjacent diseases) - do they receive systematically, in addition to other therapy, the antibiotics as the prevention of superimposed bacterial (or often fungal) infection, when, before or after they would develop respiratory insufficiency?
AGAIN. Does the doctrine not to give antibiotics from the start, expose the COPD and the patients at risk, to deadly bacterial / fungal infection complications!!!