Peculiarities of antimicrobial therapy of viral and bacterial pneumonia in patients with coronavirus disease
Authors: Nesterenko O.M. 
Published: July 2021

Background. The coronavirus pandemic (COVID-19) currently dominates all health problems. Adequate initial antimicrobial therapy of viral and bacterial pneumonia in patients with COVID-19 requires compliance with a number of features that are fundamentally important in the context of global growth of resistance of pathogenic flora to antimicrobial drugs.

Objective. To describe the features of antimicrobial therapy of viral and bacterial pneumonia in patients with COVID-19.

Materials and methods. Analysis of literature data on this issue.

Results and discussion. Severe coronavirus infection triggers an avalanche-like generalized inflammatory response with rapid vascular endothelial damage. Lungs is the main target organ of this aggression. A significant part of all endothelial cells of the body is concentrated in the lungs, so the cascade of multiorgan disorders begins with them. Liver, intestines, kidneys and muscles are the organs that suffer from extrapulmonary manifestations of COVID-19. SARS-CoV-2 сoronavirus also has neurotropism, so it is able to affect the nervous system, both central and peripheral. The pathogenesis, diagnosis and treatment of COVID-19 should be considered in terms of the approaches used in sepsis. This disease is characterized by the following laboratory changes: increased content of C-reactive protein, leukocytosis or leukopenia, lymphopenia, neutrophilia, increased activity of alanine and aspartate aminotransferases, creatine phosphokinase, lactate dehydrogenase, bilirubin and creatinine concentrations. However, sufficiently sensitive and specific markers for the diagnosis and prediction of COVID-19 are currently lacking. Until the results of the polymerase chain reaction for SARS-CoV-2 and, consequently, the confirmation of COVID-19, are absent, all patients with severe pneumonia and acute respiratory distress syndrome should be treated as patients with acute severe community-acquired pneumonia. Empirical combination antibiotic therapy should be started immediately. Patients over 60 years of age with pre-existing comorbidities need special attention. The spectrum of microbial flora in such patients includes Streptococcus pneumoniae, Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, gram-negative enterobacteria. This must be taken into account when choosing an antibiotic. In presence of intracellular pathogens, fluoroquinolones have an advantage over macrolides and tetracyclines. Due to the growing resistance of hospital flora to macrolides and the high risk of resistance to them in outpatient flora, the initial use of fluoroquinolones is one of the main trends in modern antibiotic therapy. The advantages of levofloxacin are the possibility of administration in short courses (750 mg once a day for 5 days), a wide activity spectrum, the ability to overcome the basic mechanisms of resistance, a good safety profile. Intravenous administration of levofloxacin is not inferior to the effectiveness of the combination of β-lactams and macrolides and can be completed by transferring the patient to oral treatment. For the treatment of patients at risk of Pseudomonas aeruginosa infection, combination therapy is prescribed – antipseudomonad cephalosporins of III-IV generation in combination with aminoglycosides, ciprofloxacin or levofloxacin. Alternatively, carbapenems are prescribed in combination with aminoglycosides (tobramycin – Braxon, “Yuria-Pharm”) or fluoroquinolones (levofloxacin – Leflocin, “Yuria-Pharm”). When methicillin-resistant Staphylococcus aureus is detected, the use of linezolid (Linelid, “Yuria-Pharm”) is advisable. Antibiotic therapy is often accompanied by fungal infections. In severe cases of the latter, as well as in pulmonary aspergillosis voriconazole (Vizealot, “Yuria-Pharm”) is prescribed.

Conclusions. 1. Severe coronavirus infection triggers an avalanche-like generalized inflammatory reaction with rapid damage to the vascular endothelium. 2. In the presence of intracellular pathogens, fluoroquinolones have an advantage over macrolides and tetracyclines. 3. The initial use of fluoroquinolones is one of the main trends in modern antibiotic therapy. 4. In the detection of methicillin-resistant Staphylococcus aureus, it is advisable to use linezolid. 5. In severe fungal infections and pulmonary aspergillosis, voriconazole is prescribed.