Professor Kuang-Yao Yang
Director of Respiratory Critical Care Unit,
Department of Chest Medicine,
Taipei Veterans General Hospital,
Taiwan

The COVID-19 pandemic has led to increased prevalence of community-acquired pneumonia (CAP), which is recognised as a significant cause of hospitalisation and mortality.¹ The heightened awareness of viral respiratory infections, coupled with the health risk of co-infections and growing antibiotic resistance, has prompted a paradigm shift in treatment strategies.

Professor Kuang-Yao Yang, based in Taiwan, provides valuable insights on the empirical selection and administration of antibiotics, and discusses future directions of CAP management in the context of the post-COVID-19 era.

Q1: Have there been any notable changes in the microbiological profile of patients with CAP in the post-COVID-19 era?
Throughout the COVID-19 pandemic, there was a reduction in the prevalence of common causative pathogens of CAP such as Streptococcus pneumoniae, Haemophilus influenzae and Mycoplasma pneumoniae. On the other hand, there was an observed increase in the prevalence of other pathogens such as Pseudomonas aeruginosa, Klebsiella pneumonia and respiratory syncytial virus during this period.² Despite these shifts in prevalence during the pandemic, the major microbiological profiles observed in the post-COVID-19 era are similar to the pre-pandemic years. Notably, pneumococcus remains a significant pathogen associated with CAP even in the post-COVID-19 era.

Q2: Could you describe the factors influencing your selection of empiric antibiotic therapy for patients with CAP in the post-COVID-19 era? Has this differed from your decision-making process in the midst of the pandemic?
Disease severity assessments, such as CURB-65 and pneumonia severity index (PSI) score, the presence of comorbidities and a recent history of antibiotics exposure are major factors that could be taken into consideration for the selection of empiric antibiotics for patients with CAP in the post-COVID-19 era. In addition, it is essential to consider the risk factors associated with infections caused by Pseudomonas aeruginosa or Methicillin-resistant Staphylococcus aureus.

The decision-making process for empiric antibiotic therapy in the post-COVID-19 era has not significantly differed from that used during the midst of the pandemic. Clinicians in Taiwan continue to adopt established guidelines for the management of CAP, including the Taiwan pneumonia guidelines and 2019 American Thoracic Society and the Infectious Diseases Society of America (ATS/IDSA) CAP guidelines.^3,4

Q3: What are the key challenges for managing CAP in the post-COVID-19 era? Are there any specific antibiotic guidelines or recommendations that you feel need to be revised or updated?
The most important and challenging aspect of CAP management during the post-COVID-19 era remains the timely identification of possible pathogens and the appropriate use of antibiotics. The emergence of the point-of-care multiplex polymerase chain reaction (PCR) assay, facilitating rapid identification of pathogens and patterns of antimicrobial resistance associated with CAP, holds promise for optimising clinical outcomes, especially among patients with severe pneumonia. In terms of antibiotic guidelines and recommendations, it is essential for guidelines to address the role of novel diagnostic tools, such as the multiplex PCR assay, for the management of CAP in the post-COVID-19 era.

Q4: How can healthcare providers strike a balance between the adequate use of antibiotics for CAP and the need to minimise the risk of antibiotic resistance, particularly in the context of severe COVID-19 co-infection?
It is always important to strike an optimal balance between effective antibiotics use for CAP and the pressing issue of antibiotic resistance. To address this balance, healthcare providers often adopt a multifaceted strategy. This involves continuous assessment of the patient’s clinical condition, coupled with a discerning interpretation of microbiological findings. The decision to de-escalate or even discontinue antibiotics is guided by both microbiology results and clinical judgement. For patients with a low likelihood of bacterial co-infection and without shock, the guidelines suggest postponing antibiotics while maintaining close monitoring of the patient’s condition.⁵ For patients with severe COVID-19 co-infection, a prompt initiation of empiric antibiotics for CAP is suggested, preferably within an hour of sepsis identification, in accordance with the guidelines stipulated by the Surviving Sepsis Campaign.

Q5: What is your opinion on the role of fluoroquinolones, such as levofloxacin, in the treatment of patients with CAP and COVID-19 infection? Please provide an overview of the existing evidence and guidelines supporting this regimen, including dose selection and duration of treatment.
Respiratory fluoroquinolones, which encompass agents such as moxifloxacin and levofloxacin, were widely used in the context of CAP management during COVID-19 pandemic. The role of levofloxacin in empiric antibiotics and definitive treatment for CAP is well established by robust scientific literature. The prescription of levofloxacin can be effectively guided by the directives outlined in the Taiwan pneumonia guidelines.³

References

1. Erdahl L, Ballester M. Citing websites: Community-Acquired Pneumonia in the Era of COVID-19. Available from: https://www.reliasmedia.com/articles/149264-community-acquired-pneumonia-in-the-era-of-covid-19. Accessed: 12 May 2023.
2. Liu YN, et al. Lancet Microbe 2023;4:e330–
3. Chou CC, et al. J Microbiol Immunol Infect 2019;52:172–
4. Metlay JP, et al. Am J Respir Crit Care Med 2019;200:e45–
5. Evans L, et al. Crit Care Med 2021;49:1974–