Upfront Empiric CAP Antimicrobial Therapy Linked to Less VAP in Severe COVID-19

Can upfront empiric community-acquired pneumonia antimicrobial therapy reduce ventilator-associated pneumonia rates in patients with COVID-19 requiring MV?

In patients with severe SARS-CoV-2 infection who require invasive mechanical ventilation (MV), the early empiric administration of community-acquired pneumonia (CAP) antimicrobial therapy is associated with reduced rates of ventilator-associated pneumonia (VAP), according to research presented at the American College of Chest Physicians (CHEST) 2022 Annual Meeting, held October 16 to 19, in Nashville, Tennessee.

Patients with severe COVID-19 infection often require invasive MV, and are therefore at an increased risk for VAP. Researchers sought to determine whether upfront empiric CAP antimicrobial therapy could reduce rates of VAP these patients.

A retrospective study was conducted among 113 adult patients (median age, 65 years [range 53-71 years]; 65% male) admitted to the medical intensive care unit at a tertiary care medical center with laboratory-confirmed COVID-19 between March 2020 and December 2020.

The median duration of MV was 16 days (range, 11 to 24 days); 25% of the participants underwent a tracheostomy; and 38% of the patients died during their hospitalization. In 42% of study participants, empiric CAP antimicrobial therapy was initiated on day 1 of hospitalization, which consisted mainly of azithromycin combined with ceftriaxone in all but 1 of these individuals.

Per univariate analysis, the duration of MV (P =.003), the absence of empiric treatment of CAP (P =.000), and male gender (P =.045) were all significantly associated with the development of VAP (which was defined as the “presence of positive sputum culture and worsening clinical and/or radiographic status requiring new antimicrobial treatment”). In contrast, neither the presence of medical comorbidities nor COVID-19-targeted treatment (ie, the administration of remdesivir, hydroxychloroquine, systemic corticosteroids, or monoclonal antibodies) was associated with VAP.

On multivariate logistic analysis, the lack of upfront empiric CAP antimicrobial treatment on admission was significantly associated with the development of VAP when adjustments were made for MV duration and the participant’s gender (odds ratio, 0.23; 95% CI, 0.09-0.54; P =.001).

According to the authors, “Further prospective randomized studies are needed to better evaluate the potential risks and benefits of early empiric antibiotics to prevent hospital acquired infections in COVID-19 patients.”


Wakefield C, Kim S, Geroux R, Seder CW, Balk RA. Upfront community-acquired pneumonia antimicrobial therapy is associated with reduced rates of ventilator-associated pneumonia in patients with COVID-19. Presented at: CHEST 2022 Annual Meeting; October 16-19, 2022; Nashville, TN.