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.