Clinical Practice Supports image

Antimicrobial Stewardship (AMS)

Resources to help you ensure the safe and effective use of antimicrobials in NSHA patients.

Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD): An acute worsening of respiratory symptoms that is sustained (48 hours or more) and results in additional therapy. 

  • May be triggered by infections, airway irritants, non-adherence to COPD treatments, pulmonary embolism, pulmonary edema, pneumothorax, etc.  

Last revised August 2023

Respiratory viral infections 

  • Most commonly human rhinovirus (“common cold”)
  • Influenza 
  • COVID-19

Respiratory bacterial infections

  • Haemophilus influenzae
  • Moraxella catarrhalis
  • Streptococcus pneumoniae

Last revised August 2023

Although viral and bacterial infections may cause AECOPD, it is important to rule out non-infectious precipitants including pulmonary embolism, pneumothorax, heart failure or pleural effusion.

Viral causes

  • Influenza testing during periods of increased influenza activity
  • COVID-19 

If radiographic and clinical evidence of pneumonia, choose antibiotic based on CAP section of Handbook.

Last revised August 2023

  • Systemic (oral route preferred) corticosteroids for moderate to severe (e.g., AECOPD requiring admission to hospital) exacerbations. 
    • Short courses (e.g., 5 days) are recommended over longer courses.
  • Optimize bronchodilation with addition of short-acting inhaled bronchodilators.

Last revised August 2023

  • Antibiotics used for AECOPD ONLY if increased sputum purulence with:
    • Increase in dyspnea

    OR

    • Increase in sputum volume
  • If a patient has received an antibiotic in the last three months, it is recommended to switch to an alternative class.
  • Macrolides are not recommended as first line empiric therapy due to poor Haemophilus coverage and high rates of Streptococcus pneumoniae resistance.
  • Fluoroquinolones should be reserved for severe cases or failure with first line options due to concerns regarding resistance and C. difficile.
  • Treatment failure is defined as clinical deterioration after 72 hours or no improvement after completion of first line treatment.

Last revised August 2023

The recommended duration of antibiotic therapy in most patients is 5 days (except azithromycin)

Last revised August 2023

  • Review inhaler technique and adherence to inhaler regimen at every opportunity. Optimize inhaler therapy as required.
  • Smoking cessation
  • COPD Education and/or pulmonary rehabilitation referral.
  • Influenza, COVID-19 and pneumococcal vaccinations as indicated
  • Ensure appropriate follow-up is arranged with primary care provider within 2-3 weeks of discharge from hospital. 
  • Spirometry near time of discharge should be done if no prior confirmation of COPD.

Last reviewed August 2023

1. Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4):2300239.

2. Dalhousie Academic Detailing Service. Antibiotics: Why and Why Not. 2012. Available from: https://cdn.dal.ca/content/dam/dalhousie/pdf/faculty/medicine/departments/core-units/cpd/academic-detailing/antibiotics_2012.pdf

3. Ospina MB, et al. for the COPD PRIHS-2 Group. Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease. BMJ Open Resp Res 2018;5:e000265. doi:10.1136/bmjresp-2017-000265.

Last revised August 2023

Community-Acquired Pneumonia (Adult)

Community-acquired pneumonia (CAP):  acute infection acquired outside of hospital or within 48 hours of admission

Last revised March 2020

  • Viruses are common causative pathogens and frequently implicated in co-infections with bacteria.
  • The most common bacterial pathogen is Streptococcus pneumoniae.
    • Less common bacteria: Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, Legionella pneumophila, Enterobacterales (Enterobacteriaceae), Mycoplasma pneumoniae

Last updated March 2020

  • Differential diagnoses: acute exacerbation of COPD, acute bronchitis, heart failure, and pulmonary embolism
  • Infiltrate on chest radiograph with supportive clinical findings:
    • Symptoms include new onset fever, cough, sputum production, dyspnea, tachypnea, pleuritic chest pain 
    • Physical findings consistent with signs of air space disease (e.g. crackles, bronchial breath sounds)
    • If no infiltrate on initial x-ray, patients should be reassessed within 48 to 72 hours if a high clinical suspicion of pneumonia remains
  • Risk stratify using clinical judgement or the CRB-65 score:
CRB-65: Patient Criteria Points
Confusion (either based on specific mental test OR new disorientation to person, place or time) 1
Respiratory rate 30 breaths or more per minute 1
Hypotension (systolic less than 90 mm Hg OR diastolic less than 60 mm Hg) 1
Age 65 years old or greater 1

⇩

CRB-65 Score 30 Day Mortality Management Setting
0 points AND O2 sat greater than 92% (on room air) 2.4 % (low risk) Usually outpatient treatment
1-2 points 13.3 % (moderate risk) Consider admission to inpatient ward
3-4 points 34.3 % (high risk) Often requires an ICU admission

Last reviewed March 2020

  • This guideline does not apply to patients with cystic fibrosis, febrile neutropenia, structural lung disease, and others colonized with multidrug-resistant microorganisms.
  • Macrolides (e.g., azithromycin) are not first line because of poor S. pneumoniae coverage
  • Consider testing for Legionella urinary antigen in severe CAP (requiring ICU admission) or if patient is associated with a local Legionella outbreak 
  • Influenza testing: recommended for CAP requiring hospital admission during periods of high influenza activity
  • Sputum cultures if any one of:
    • ICU admission requiring intubation, starting empiric treatment for or recent infection with MRSA or resistant Gram-negatives (e.g. Pseudomonas), hospitalization and receipt of parenteral antibiotics in the last 90 days, or copious sputum production
    • Low quality results may be misleading as cultured bacteria often represent colonization 
  • Blood cultures if any one of:
    • Fever, ICU admission requiring intubation, starting empiric treatment for or recent infection with MRSA or resistant Gram-negatives (e.g. Pseudomonas), or hospitalization and receipt of parenteral antibiotics in the last 90 days
  • Empiric coverage of atypical bacteria (e.g. Legionella, Mycoplasma):
    • Outpatient setting: not recommended
    • Non-ICU hospitalization: benefit is unclear and there is risk of adverse effects, especially in patients with a predisposition for QTc prolongation from macrolides and multiple adverse effects from fluoroquinolones (i.e., levofloxacin)
    • ICU patients:  coverage for Legionella is routinely recommended (see below)
  • Aspiration pneumonia
    • Antimicrobial prophylaxis at the time of aspiration is not beneficial. Provide supportive care and reassess in 48 hours for signs and symptoms of pneumonia
    • Routine addition of anaerobic coverage, such as metronidazole, is not recommended unless treating an empyema or lung abscess.

Last reviewed March 2020

*May require renal dose adjustments. Please see Nova Scotia Health Firstline app

Note: amoxicillin/clavulanate unnecessarily broad for most community acquired pneumonia in previously healthy individuals.
  • Oseltamivir 75 mg PO BID x 5 days (dose adjust in renal dysfunction) recommended as empiric treatment in hospitalized patients with suspicion of influenza, regardless of timing of symptom onset. See influenza guideline.

Last reviewed June 2023

Usual duration is 5 days, exceptions include:

  • The patient is not yet clinically stable: ongoing vital sign abnormalities including tachycardic, tachypnea, hypotension, high oxygen requirements, or persistent fever
  • Associated bloodstream infections
  • Duration in cases of S. aureus or in known resistant Gram negative bacteria is at least 7 days; ID consultation should be considered
  • Longer durations required for empyema and lung abscess

Last reviewed March 2020

  • Review IV antibiotics within 48 hours of treatment initiation and consider switching to PO antibiotics once patient is clinically improving (e.g., afebrile, hemodynamically stable, adequate PO intake).
    • CAP is often inappropriately treated with prolonged IV therapy and prolonged antibiotic courses.
  • If tuberculosis is a concern, fluoroquinolones can interfere with TB cultures and should be avoided
  • If colonized/infected with nontuberculous mycobacteria (NTM), avoid macrolides since resistance can develop

Last reviewed March 2020

1. Jain S, Self WH, Wunderink RG, Fakhran S, Balk R, Bramley AM, et al. Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults. N Engl J Med. 2015; 373;5: pp 415-427.

2. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. Am J Respir Crit Care Med. 2019; Vol 200 (Iss 7): pp 809-821.

3. National Institute for Health and Care Excellence. Pneumonia (community-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed September 18, 2019

4. Antibiotics Why and Why Not 2018 Dalhousie CPD Academic Detailing Service, November 2018. http://www.medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service.html. Accessed August 12, 2019

5. Management of Community Acquired Pneumonia in Adults. SHS + UHN Antimicrobial Stewardship Program, 2018. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed August 19, 2019.

Last reviewed March 2020

Hospital-Acquired Pneumonia

Hospital-acquired pneumonia (HAP): pneumonia not present at the time of hospital admission and occurring ≥ 48 hours after admission

Last reviewed March 2024

  • Streptococcus pneumoniae
  • Staphylococcus aureus
  • Haemophilus influenzae
  • Gram-negative bacilli
    • Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia spp., Pseudomonas aeruginosa

Last reviewed March 2024

  • Sputum culture
  • Blood cultures (aerobic and anaerobic) x 2 sets using two sites, at least one from peripheral site
  • Suspect HAP if
    • Chest imaging shows new pulmonary infiltrate, PLUS one of:
      • Fever
      • Purulent respiratory secretions
      • Leukocytosis
      • Dyspnea or increase in oxygen requirements

Last reviewed March 2024

  • Usual duration of therapy is 7 days
  • Longer duration indicated for abscess, empyema, or severely immunocompromised

Last reviewed March 2024

  • Therapy should be tailored once culture and sensitivity results or other diagnostic information becomes available.
  • Aspiration pneumonitis: antimicrobial therapy is not indicated for acute macroaspiration events. Pneumonia may develop, reassess after 48 hours.            
  • Aspiration pneumonia: routine addition of anaerobic coverage, such as metronidazole, is not recommended unless treating an empyema or lung abscess.
  • Consider double antimicrobial coverage for Pseudomonas only if critically ill with high suspicion of infection with resistant microorganism in patients who have receieved recent broad spectrum antimicrobial therapy. Narrow to single agent once sensitivities available.

Last reviewed March 2024

  • Review patient’s prior culture results and prior antibiotic use to inform empiric choices

 

Risk Factors Regimen
  • No rapid clinical deterioration
  • Not admitted to ICU
  • No IV antibiotic use within preceding 90 days

Ceftriaxone 1 g IV q24h

OR

Amoxicillin-clavulanate* 875 mg PO BID

OR

Levofloxacin* 750 mg PO/IV q24h

Any ONE of the following:

  • HAP requiring ICU management: septic shock and/or intubation
  • Colonization or prior infection with Pseudomonas or other resistant Gram-negative bacilli (e.g. extended spectrum beta-lactamase producing E. coli, Klebsiella)
  • Prolonged hospitalization (more than 2 weeks)
  • IV antibiotic use within 90 days

Piperacillin-tazobactam* 4.5g IV q6h†

OR

Meropenem* 500 mg IV q6h

Preferred if: colonized/infected with piperacillin-tazobactam resistant microorganism OR IgE mediated penicillin allergy

If MRSA suspected:

  • Known MRSA colonization
  • Previous MRSA infection

ADD:

Vancomycin* IV

(See NSHA Antimicrobial Handbook or Spectrum App)

*May require renal dose adjustments, see NSHA Spectrum app or dosing table

†Critical care may have a prolonged infusion protocol

 

 

Last reviewed March 2024

1. Kalil AC, Metersky ML, Klompas M, Musced-ere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-Acquired and Ventilator-Associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63: pp e61-e111.

2. National Institute for Health and Care Excellence. Pneumonia (hosptial-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed March 13, 2020.

3. Management of Hospital-Acquired Pneumonia in Adults. SHS + UHN Antimicrobial Stewardship Program, 2018. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed March 13, 2020.

4. Treatment Guidelines. Sunnybrook Health Sciences Centre. https://sunnybrook.ca/content/?page=antimicrobial-stewardship-treatment-guidelines. Accessed April 5, 2020.

Last reviewed March 2024

Ventilator-Associated Pneumonia in Adults

Ventilator-associated pneumonia (VAP): pneumonia occurring 48 hours or more after mechanical ventilation

Last reviewed April 2020

  • Staphylococcus aureus
  • Haemophilus influenzae
  • Gram-negative bacilli
    • Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia spp., Pseudomonas aeruginosa

Last reviewed April 2020

  • Sputum culture
    • Endotracheal aspiration is generally preferred over invasive sampling (e.g., bronchoalveolar lavage)
  • Blood cultures (aerobic and anaerobic) x 2 sets using two sites, at least one from peripheral site
  • Suspect VAP if
    • Chest imaging shows new pulmonary infiltrate, PLUS one of:
      • Fever
      • Purulent respiratory secretions
      • Leukocytosis
      • Increase in oxygen requirements or ventilatory settings

Last reviewed April 2020

  • Usual duration of therapy is 7 days
  • Longer duration indicated for abscess, empyema, or severely immunocompromised

Last reviewed April 2020

  • Antimicrobial therapy should be narrowed based on microbiology of respiratory samples.
  • Stenotrophomonas maltophilia can cause VAP and should be suspected if patients is not improving despite broad-spectrum antimicrobial therapy. Trimethoprim/sulfamethoxazole is the antibiotic of choice.
  • Candida is a very rare cause of pneumonia and does not require treatment unless evidence of systemic infection such as bloodstream infection.
  • Respiratory cultures can continue to be positive despite successful treatment; avoid repeating cultures if patient is clinically improving.
  • Consider double antimicrobial coverage for Pseudomonas only if critically ill with high suspicion of infection with resistant microorganism in patients who have receieved recent broad spectrum antimicrobial therapy. Narrow to single agent once sensitivities available.

Last reviewed April 2020

Considerations Regimen

 

 

First Line

Piperacillin-tazobactam* 4.5g IV q6h†

OR

Meropenem* 500 mg IV q6h

Preferred if: colonized/infected with piperacillin-tazobactam

resistant microorganism OR IgE-mediated penicillin allergy

If MRSA suspected:

  • Known MRSA colonization
  • Previous MRSA infection

Add

Vancomycin* IV

(See NSHA Antimicrobial Handbook or Spectrum App)

 

 

Last reviewed January 2024

1. Kalil AC, Metersky ML, Klompas M, Musced-ere J, Sweeney DA, Palmer LB, et al. Management of Adults With Hospital-Acquired and Ventilator-Associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63: pp e61-e111.

2. National Institute for Health and Care Excellence. Pneumonia (hosptial-acquired): antimicrobial prescribing. NICE Guideline. 2019. www.nice.org.uk/guidance/ng138. Accessed March 13, 2020.

3. Ventilator-Associated Pneumonia. SHS + UHN Antimicrobial Stewardship Program, 2020. https://www.antimicrobialstewardship.com/community-acquired-pneumonia. Accessed March 13, 2020.

Last reviewed April 2020

Seasonal Influenza

  • Influenza A and B cause seasonal outbreaks
  • Co-infection with bacterial microorganisms (e.g., Streptococcus pneumoniae, Staphylococcus aureus) may be present

Last reviewed December 2023

  • Consider influenza when circulating in the community
    •     Weekly surveillance reports are available at weekly FluWatch report
  • Influenza is characterized by acute respiratory illness symptoms which vary and may include:
    •     Systemic symptoms: fever, myalgia, arthralgia, headache, nausea, vomiting, diarrhea
    •     Upper respiratory tract symptoms: sore throat, rhinorrhea
    •     Lower respiratory tract symptoms: cough, shortness of breath
  • Nasopharyngeal (NP) swab detects presence of influenza A and B and respiratory syncytial virus (RSV). Testing detects live and dead virus, so test of cure unnecessary in most patients
  • Important to exclude COVID-19 via rapid or PCR test which may present with similar signs and symptoms

 

Last reviewed December 2023

  • Initiate droplet/contact precautions
  • Empiric antiviral treatment for influenza infection should be based on acute respiratory illness symptoms, influenza circulating in the community, and risk factors for developing complications (regardless of vaccination status or onset of symptoms).
    • Prescribe oseltamivir as early as possible for patients who test negative for COVID-19† and
      1.  have suspected or test-confirmed severe, complicated, or progressive* influenza OR
      2.  are hospitalized with suspected or test-confirmed influenza OR
      3.  have suspected or test-confirmed influenza and are at higher risk of complications, including the age groups, chronic medical conditions, and persons outlined in Table A
  • For suspected influenza cases awaiting influenza PCR result, discontinue oseltamivir if the lab test returns as negative
  • †For severe illness, oseltamivir may be prescribed in advance the return of COVID-19 testing. Consider treatment of bacterial co-infection (see CAP chapter) if severe illness at onset or if deterioration after initial improvement.
  • Note: antiviral therapy generally works best when initiated within 48 hours of symptom onset
Table A. Risk factors for complications of influenza illness in adults3
  • Asthma and other chronic pulmonary disease, including bronchopulmonary dysplasia, cystic fibrosis, chronic bronchitis, and emphysema
  • Cardiovascular disease (excluding isolated hypertension), including congenital and acquired heart disease, such as congestive heart failure and symptomatic coronary artery disease.
  • Renal disease
  • Chronic liver disease
  • Diabetes mellitus and other metabolic diseases
  • Anemia and hemoglobinopathies, such as sickle cell disease
  • Cancer, immunosuppression, or immunodeficiency due to disease (e.g.: HIV infection, especially if CD4 is <200) or management of underlying condition (solid organ transplant or hematopoietic stem cell transplant recipients)
  • Neurological disease and neurodevelopmental disorders that compromise handling of respiratory secretions (cognitive dysfunction; spinal cord injury; neuromuscular, neurovascular, neurodegenerative and seizure disorders; cerebral palsy; metabolic disorders)
  • Individuals aged 65 years or older
  • People of any age who are residents of nursing homes or other chronic care facilities
  • Pregnancy and up to 4 weeks postpartum regardless of how the pregnancy ended‡
  • Obesity with a BMI greater than or equal to 40 or a BMI greater than 3 z-scores above the mean for age and gender
  • Indigenous peoples

‡The risk of influenza-related hospitalization increases with length of gestation (i.e., it is higher in the third trimester than in the second)

Last reviewed December 2023

Oseltamivir (Tamiflu®) 75 mg PO BID x 5 days

  • Renal adjustment if necessary (see Table B). Recommended to dose based on recent serum creatinine (SCr), i.e., within past 12 months. If recent SCr unavailable, begin therapy without delay and adjust as necessary when bloodwork returns.
  • For administration via NG or OG: capsules may be opened and contents administered, or if available suspension may be used
  • High-dose oseltamivir (150 mg BID) is not recommended
Table B: Adult dosing of oseltamivir
 

 

Greater than 60 mL/min

 CrCl

 

PD

 

IHD

 

CRRT
31-60 mL/min 10-30 mL/min Less than 10 mL/min

Oseltamivir   (PO/NG/OG)

 75 mg BID 30 mg BID 30 mg daily 75 mg x 1 dose 30 mg x 1 dose 75 mg x 1 and after each hemodyalysis 75 mg daily

Last reviewed December 2023

  • 5 days is the standard duration (except in CrCl less than 10 mL/min and PD as above)
  • In critically ill and immunocompromised patients, longer courses of up to 10 days may be appropriate. Consider ID consult.

Last reviewed December 2023

  • Refer to guidance in IWK Firstline for influenza management in pregnancy and pediatrics.
  • Prophylaxis in the setting of an outbreak may be prescribed in consultation with Public Health, Infection Prevention and Control, or local guidelines. For oseltamivir dosing, see Firstline.
  • Zanamavir is available but not recommended as first-line treatment. Peramavir and baloxavir marboxil are approved in Canada, but no formal recommendation for use has been made and they are non-formulary within NS Health.
  • Drug resistance is rare. If suspected consult ID.

Last reviewed December 2023

1. Government of Canada. Flu (influenza) for Health Professionals. Accessed online 09/2023. https://www.canada.ca/en/public-health/services/diseases/flu-influenza/health-professionals.html

2. Communicable disease Prevention and Control -Respiratory Watch Report. Accessed online 9/2023. https://novascotia.ca/dhw/cdpc/respiratory-watch.asp

3. Aoki FY, et al. Use of antiviral drugs for seasonal influenza: Foundation document for practitioners—Update 2019. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2019;4(2):60–82.

4. Aoki FY, et al. 2021–2022 AMMI Canada guidance on the use of antiviral drugs for influenza in the COVID-19 pandemic setting in Canada. Official Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2022;7(1):1-7.

5. SHS-UHN Antimicrobial Stewardship Program: https://www.antimicrobialstewardship.com/influenza-treatment. Accessed online 09/2023.

6. Ontario Agency for Health Protection and Promotion (Public Health Ontario). At a glance: antiviral medications for seasonal influenza: public health considerations. Toronto, ON: King's Printer for Ontario; 2022.

7. Harrison R, et al. AMMI Canada 2023 update on influenza: Management and emerging issues. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2023;8(3):176-86.

Last reviewed December 2023

Coronavirus Disease (COVID-19)

Viral infection with SARS-CoV-2

  • Clinical presentation varies from asymptomatic to severe illness.
  • Common symptoms include:
    • new tiredness
    • new or worsening cough
    • fever (chills, sweats)
    • new shortness of breath (SOB) or difficulty breathing
    • change in smell or taste
    • sore throat
    • runny/stuffy nose/sneezing
    • headache
    • nausea
    • diarrhea
    • vomiting
  • Rapid antigen testing or PCR testing may be used to diagnose COVID-19, depending on setting.

Last reviewed Dec 2023

  • Asymptomatic: no symptoms of COVID-19
  • Non-severe: COVID-19 symptoms WITHOUT evidence of lower respiratory disease:
    • SpO2 greater than or equal to 94% OR no change from baseline AND
    • No new hypoxemia or desaturation with minimal exertion
    • No new significant SOB (or worsening baseline SOB for those with respiratory disease at baseline)
    • No airspace disease on chest x-ray if performed
  • Moderate-severe: Evidence of lower respiratory disease:
    • SpO2 less than 94% on room air or requiring supplemental oxygen AND/OR
    • New or worsening baseline hypoxemia
    • Respiratory rate above 30 breaths/min
    • Airspace disease on chest x−ray

Last reviewed Dec 2023

  • Initiate droplet/contact precautions and escalate to airborne precautions if performing aerosol-generating medical procedures.
  • Approximately 80% of cases are mild, uncomplicated upper respiratory tract viral infection. Risk factors for poor outcome include older age, immunocompromise, insufficient vaccination, and multiple comorbidities (e.g., diabetes, chronic lung disease, cardiovascular disease, active cancer, etc.).
  • COVID-19 may acutely exacerbate pre-existing patient conditions such as heart failure or COPD, which may present with similar and overlapping symptoms. Clinical judgement is necessary to determine the most likely underlying cause of symptoms (i.e., hypoxia) and how to best direct therapy.

Last reviewed Dec 2023

  • A mainstay of treatment for all patients is supportive care (symptom management, rest, etc.) including supplemental oxygen, ventilation, and prone positioning as appropriate.
  • For inpatients, ensure appropriate thromboprophylaxis (e.g., dalteparin 5000 units subcut daily) is ordered or use full anticoagulation if there is a separate indication (e.g., strong suspicion of thrombus or pre-existing condition like atrial fibrillation).
  • Initiation of COVID-19 treatments should take into consideration the patient’s disease severity, duration of symptoms, immunization history, risk factors for progressing to more severe disease, and patient-specific factors such as pregnancy, drug-drug-interactions, etc.
  • Some therapeutics (i.e., nirmatrelvir/ritonavir [Paxlovid®], remdesivir [Veklury®], tocilizumab [Actemra®], baricitinib [Olumiant®]) are prescribed only by designated prescribers in consultation with the appropriate COVID-19 Therapeutics Team. Contact information and referral process.
Asymptomatic COVID-19
No COVID-directed therapy indicated; monitor for symptoms and changes in clinical status
Non-Severe COVID-19  

Consider inhaled budesonide 

  • Budesonide MDI 800 mcg inh BID x 14 days or until symptom recovery
    • In those with mild respiratory symptoms (especially cough)
    • Initiate within 14 days of symptom onset
    • Do NOT substitute with nebules, alternative inhaled or oral/IV corticosteroids

+/- anti-SARS-CoV-2 antiviral

  • Nirmatrelvir 300 mg (2x 150 mg tablets) AND ritonavir 100 mg (1x 100 mg tablet) [Paxlovid®] po BID* x 5 days 
    • Initiate as early as possible and within 5 days of symptom onset. 
    • MANY drug-drug interactions which may require temporary adjustment of chronic medications. 

OR

  • Remdesivir* 200 mg IV on day 1 then 100 mg IV daily on days 2 and 3
    • Initiate as early as possible and within 7 days of symptom onset.
Moderate to Severe COVID-19

Oral/IV corticosteroid

  • Dexamethasone 6 mg po/IV daily x 10 days or until hospital discharge if sooner
    • For SpO2 less than 94% on room air or supplemental O2, or mechanical ventilation

+/- anti-SARS-CoV-2 antiviral

  • Remdesivir* 200 mg IV on day 1 then 100 mg IV daily on days 2 through 5
    • Generally initiated in non-intubated individuals 
    • May be extended to 10 days depending on clinical response

+/- additional anti-inflammatory therapy

  • Tocilizumab 8 mg/kg to a maximum of 800 mg IV x 1 dose
    • If SpO2 less than or equal to 92% on room air or supplemental O2, and systemic inflammation (e.g., CRP above 75 mg/L)

OR

  • Baricitinib* 4 mg po daily x up to 14 days or hospital discharge if sooner

*May require renal dose adjustments. Please see NS Health Firstline app

  • Rates of bacterial co-infection with COVID-19 are low, approximately 7-9%. If severe illness at onset or if deterioration after initial improvement, consider treatment of bacterial co-infection (see CAP, HAP, or VAP chapter as appropriate)

Last reviewed Dec 2023

  • Patients at risk of persistent COVID-19 infection (i.e., those with severe immunocompromise) may be considered for a longer total treatment duration.
  • Hospitalized patients with influenza and COVID-19 co-infection who are receiving remdesivir or other SARS-CoV-2 antivirals should also receive oseltamivir.
  • For management of special populations (e.g., pregnancy, pediatrics) refer to Firstline.

Last reviewed Dec 2023

1. Centers for Disease Control and Prevention. Clinical considerations for care of children and adults with confirmed COVID-19. Updated August 4, 2023. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

2. World Health Organization. COVID-19 Clinical Care Pathway. Updated November 10, 2022. COVID-19 Clinical Care Pathway (who.int).

3. Langford BJ, So M, Raybardhan S, et al. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Dec;26(12):1622-1629.

Last reviewed Dec 2023

Antibiotic Use in Adult COVID-19

Most patients with COVID-19 have mild respiratory disease and recover with supportive care alone. Investigational antivirals and immunomodulatory treatments may be considered as part of approved clinical trials and will be assessed by an Infectious Diseases physician prior to initiation in Nova Scotia Health (NSH).
 

Antibiotics for bacterial pneumonia are often unnecessary in patients with COVID-19. The rates of bacterial pneumonia co-infections and secondary infections are low.

  • One review suggested the rate of bacterial co-infection in nine studies of patients with COVID-19 may be 8%
    • Co-infection on presentation may be as low as 3.5%1
    • Secondary bacterial infection during illness or hospitalization is likely higher at 15.5%1
  • CRP is a non-specific inflammatory marker and is often elevated in COVID-19
  • COVID-19 infection itself often causes persistent fever and bilateral infiltrates

Last revised November 2020

Empiric Bacterial Pneumonia Treatment in Patients With COVID-192

COVID-19 Severity Antibiotic Treatment

Mild 

  • No supplemental oxygen and typically managed as outpatients
 No antibiotic therapy

Moderate/Severe 

  • Clinical signs of pneumonia, usually managed as inpatients and may require low-flow supplemental oxygen
     

No antibiotic therapy unless strong clinical suspicion for bacterial infection such as 

  • acute fever after defervescence / initial improvement with new consolidation on chest imaging

A gradually worsening respiratory failure in the first week is more likely to be from progression of COVID-19 than from a new superimposed secondary bacterial pneumonia.
 
Critical 
  • Managed in ICU with high oxygen and/or circulatory support
 Antibiotic treatment for community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), or ventilator-associated pneumonia (VAP) as indicated (link to Spectrum)
  • If bacterial co-infection is suspected, obtain blood cultures +/- sputum cultures [latter if ICU admission requiring intubation, concern of MRSA or resistant Gram-negatives (e.g. Pseudomonas), hospitalization and receipt of parenteral antibiotics in the last 90 days, or copious sputum production]
  • Consider testing for Legionella urinary antigen in severe CAP (requiring ICU admission) or if patient is associated with a local Legionella outbreak
  • Antibiotics should be reassessed daily for de-escalation based on clinical status and microbiology results
  • Minimize duration:
    • CAP 5 days
    • HAP, VAP 7 days

Other sources of infection (e.g. UTI, cellulitis, sepsis, etc) should be assessed as usual in COVID-19 patients and treated if indicated. There is no evidence that prolonged or more aggressive antimicrobial courses are warranted in COVID-19 patients.

Antibiotics are not benign and may result in adverse events including: 

  • C. difficile infection 
  • Antimicrobial resistance
  • Nephrotoxicity
  • Arrhythmias

Last revised November 2020

1. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR, Soucy J-PR, Daneman N, Bacterial co-infection and secondary infection in patients with COVID-19:a living rapid review and meta-analysis Clinical Microbiology and Infection, https://doi.org/10.1016/j.cmi.2020.07.016

2. Ontario Clinical Practice Guidelines for Antimicrobial and Immunomodulatory Therapy. Available from: https://www.antimicrobialstewardship.com/covid-19

3. Clinical Management of COVID-19: interim guidance: World Health Organization; 2020 Available from: https://www.who.int/publications-detail/clinical-management-of-covid-19

4. Clinical Management of Patients with Moderate to Severe COVID-19 - Interim Guidance (April 2, 2020) Available from: https://www.ammi.ca/Content/Clinical%20Care%20COVID%2D19%20Guidance%20FINAL%20April2%20ENGLISH%281%29%2Epdf

5. Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing. Clin Infect Dis. 2020.

6. Wang L, He W, Yu X, Hu D, Bao M, Liu H, et al. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. J Infect. 2020;80(6):639-45.

7. Wu CP, Adhi F, Highland K. Recognition and management of respiratory coinfection and secondary bacterial pneumonia in patients with COVID-19 [published online ahead of print, 2020 May 11]. Cleve Clin J Med. 2020;ccc015.

Last reviewed November 2020

Acute Sinusitis

  • Approximately 98% of acute infections are viral
  • Rarely, bacterial causes include S. pneumoniae and H. influenzae

Last reviewed Nov 2024

  • Symptoms: purulent nasal discharge, nasal obstruction, facial pain/pressure/fullness (especially while bending forward)
  • Likelihood of viral versus bacterial infection depends on symptoms, duration, and pattern over time. Viral infections tend to improve within 7-10 days.
  • Bacterial infection more likely when:
    • Persistent symptoms for 10 or more days
    • Symptoms worsen suddenly after initial improvement
    • Severe symptoms or high fever (≥ 39oC) and purulent nasal discharge or facial pain lasting 3-4 days from the onset illness
  • Coloured mucus does not indicate bacterial infection; it is related instead to the presence of inflammation and neutrophils.
  • Imaging (i.e., x-ray) not recommended for uncomplicated cases.
  • Nasopharyngeal cultures not recommended.

Last reviewed Nov 2024

  • Some bacterial sinusitis infections will resolve spontaneously and without antibiotic treatment. Watchful waiting is a reasonable strategy for otherwise healthy individuals with symptoms for less than 10 days.
    • Consider providing patient with a ‘delayed prescription’ for antibiotics and instruct to fill only if certain criteria are met, e.g., symptoms worsen in 2-3 days or fail to improve in 5-7 days
  • Symptoms may be managed with saline nasal rinses or sprays/drops, warm facial packs, and/or analgesics.
  • Infections are considered complicated if they extend beyond the nasal cavity and para-nasal sinuses, i.e., into ophthalmologic, intracranial or surround skin and soft tissue space.
    • Red flag symptoms: orbital swelling or changes in visual acuity, severe headache, altered mental status, systemic toxicity

Last reviewed Nov 2024

If likelihood of bacterial infection is high:

  • Amoxicillin 500 – 1000 mg PO TID
    • Consider 1000 mg dose if at higher risk for for penicillin-resistant Streptococcus pneumoniae such as
      recent antibiotic use (past 3 months).

Last reviewed Nov 2024

  • Cefuroxime 500 mg PO BID
    • 1st line if patient has experienced an IgE-mediated reaction to amoxicillin
  • Doxycycline 200 mg PO x 1 for first dose, then 100 mg PO BID
  • Amoxicillin/clavulanate 875 mg PO BID
    • Reserve for patients with recent treatment with amoxicillin or if failing to improve with amoxicillin

Last reviewed Nov 2024

  • 5 days for uncomplicated infections in otherwise healthy individuals

Last reviewed Nov 2024

  • Symptoms should be improved but may not be fully resolved by the end of the treatment course. This is expected and does not indicate treatment failure.

Last reviewed Nov 2024

1. M. LeBras, Acute Rhinosinusitis: Management Considerations. RxFiles. May 2024.

2. Choosing Wisely Canada, Treating Sinus Infections: Don’t rush to antibiotics. https://choosingwiselycanada.org/wp-content/uploads/dlm_uploads/2024/04/Antibiotics-Sinus-Infections_2.pdf . Accessed June 19, 2024.

3. Antibiotics Why and Why Not 2018 Dalhousie CPD Academic Detailing Service, November 2018. https://medicine.dal.ca/departments/core-units/cpd/programs/academic-detailing-service/AC-Service-Resources.html. Accessed December 23, 2024.

Last reviewed Nov 2024