An example of standard therapy for in-patient treatment for community acquired pneumonia is ceftriaxone 1-2 g IV daily with a macrolide, usually azithromycin 500mg IV/PO x 3 days or azithromycin 500mg PO x 1 day followed by 250mg PO x 4 days (89).

In these situations, in the context of the COVID-19 pandemic, with or without prior testing results, especially in poor undeveloped countries, we propose to urgently use in patients with cough and fever with or without signs and images of pneumonia, as first choice, a Macrolide, the Clarithromycin antibiotic, not only as an anti-bacterial but also as an antiviral, anti-inflammatory, and immune-modulating agent.

Apart from penicillin allergy, adverse reactions to the recommended antibiotics, e.g. macrolides, are generally mild and uncommon. The main disadvantage of this proposed strategy is that it could tend to drive increased bacterial resistance. However, in a pandemic like this one, with a high mortality rate in a specific subpopulation, in this case the very elderly people, this needs to be weighed against the benefits of the policy (88)(89).

If Clarithromycin could have the desired anti SARS-CoV-2 effect, then, rescue prescribing strategies, initiated by the own patient at an early stage with this macrolide Clarithromycin, could aid effective delivery not only of an outstanding antimicrobial but also of an antiviral in the same tablet, significantly reducing hospital admissions, and lowering mortality.

While less antimicrobial resistance should remain a global priority, the current pandemic highlights the need for unprecedented management strategies. For example, in the current context, it may be entirely appropriate for nursing homes to have routine stockpiles of antibiotics (89), but as we have said, specifically clarithromycin. Rapid interventions like this could be life-saving, allowing rapid and appropriate prescribing decisions that could minimize morbidity and mortality of COVID-19, as well as reducing the impact of the pandemic on health services most exposed to this virus.

In this context, equipping patients and medical personnel in the first lines with rescue clarithromycin for Primary Prophylaxis as we have proposed for the first time, may be a legitimate strategy to consider in this pandemic, and should be tried in a Controlled Clinical Trial.