Stop irrational use of antibiotics to treat Covid-19

There has been a proliferation of “treatment packages” offered to people with a positive Covid-19 test, worsened by testimonies of ‘Covid-19 overcomers’ recommending a repertoire of antibiotics.
Consequently, there is a scramble for multiple drugs, resulting in several-fold price increments. One such product, Azithromycin, an anti-bacterial drug belonging to the macrolide family that is the first-choice drug for people allergic to Penicillin.   

Selling Azithromycin to people who do not need it is unethical. Epidemiologists report that among every 10 positive tests, only one to two people develop severe disease that necessitates clinical intervention. In the remaining eight out of 10 positive cases, there is little scientific justification for the casual use of antibiotics in non-hospitalised patients with no laboratory evidence of a bacterial infection.

 It is unethical to sell these antibiotics to asymptomatic patients as treatment for Covid-19 for the following reasons:
 Azithromycin does not treat Covid-19 infection. Proponents of routine Azithromycin use may argue that it has antiviral properties. However, most of these studies were either not performed on the SARS-CoV2 virus or conducted purely in the laboratory.

 For these results to have preponderance, they would have to be replicated in humans with active infection in randomised clinical trials. Out of the laboratory, one randomised clinical trial by the principle Trial Collaborative Group did not find any benefit of using Azithromycin in non-hospitalised patients.
 In a further study conducted among hospitalised patients by the Recovery Collaborative Group in the UK, Azithromycin did not improve survival or any other clinical outcomes. These results corroborate with findings of studies in other countries. 

 It is imperative to state that Azithromycin does not modulate inflammation in Covid-19 infection.  A second argument is that Covid-19 is primarily a disease of a rogue immune system that goes into self-destruction and Azithromycin offers anti-inflammatory action.  Whereas it appears to reduce mucous secretion in the lungs, the suggested mechanisms of action do not appear to interfere much with the mechanisms by which SARS-COV-2 causes inflammation in Covid-19 patients.

 As earlier mentioned, in randomised controlled trials, Azithromycin was not shown to have any significant benefit in the treatment arm. Given the presence of better-proven anti-inflammatory drugs, there is inadequate justification for its use in Covid-19. 
 Also, Azithromycin is not recommended for prophylaxis in asymptomatic Covid-19 patients.  It is argued that Azithromycin may be prescribed for the prevention of bacterial infections that may exacerbate Covid-19 infection.

 However, it should be noted that the risk of bacterial infection is very low (0-6.9 per cent) in patients with mild disease and the risk of antimicrobial resistance increases dramatically with chronic use.  This is alarming, considering that any resistance to macrolides potentially eliminates treatment options for people who cannot use Penicillin. The low rate of bacterial coinfection rate in mild Covid-19, therefore, invalidates the need for antibiotics. 

 In conclusion, most people with a positive Covid-19 test do not get severely ill and should not be given Azithromycin if there is no underlying bacterial infection because it does not add value.
 In such people, the immune system is already sufficient to fight off the infection. It is an avoidable expense, and its misuse will contribute to increased antimicrobial resistance.
 
Dr Kyoyetera Kabbale is a member of the Pharmaceutical Society of Uganda.