One of the few potentially positive impacts of the COVID-19 pandemic from a diagnostic stewardship perspective has been improved access to and utilization of respiratory viral panels. Controversy has arisen, however, as to whether two categories of adults presenting with community-acquired pneumonia with positive testing for a respiratory virus should receive empiric antibacterial therapy: outpatients with comorbitidies and inpatients with non-severe disease.
Recommendations that these two groups be treated empirically were included in recent American Thoracic Society guidelines, leading IDSA to not endorse the guidelines. A separate viewpoint piece from some of the panelists involved explores some of the potential reasons why.
A recent article in Clinical Infectious Diseases provides more fuel to the controversy. The authors retrospectively analyzed clinical outcomes from patients from five Massachusetts hospitals who were hospitalized from June 2015 to December 2024 with clinical indicators of pneumonia (impaired oxygenation, tachypnea, chest imaging) and who tested positive for a respiratory virus, who received either 0-2 days or 5-7 days of antibacterial therapy. Patients who were discharged within 96 hours or who had procalcitonin ≥ 0.25 µg/L were excluded.
After propensity weighting based on hospital site, demographics, comorbidities, mortality risk and other clinical covariates, 1,720 patients were in the 0-2-day group and 894 in the 5-7-day group. There were no significant differences between groups in length of stay, ICU admission after 48 hours, in-hospital mortality or hospital-free days. Outcomes were similar when restricted to non-SARS-CoV-2 viruses. In the influenza subgroup, odds of in-hospital mortality were lower in the 0-2-day cohort (2.0% vs. 7.6%; odds ratio, 0.25; 95% confidence interval, 0.07-0.83). Sensitivity analyses using cut points of 0-1 days or even 0 days were consistent with the primary analyses.
This article supports the notion that a full course of antibacterials likely isn’t indicated in most patients admitted with community-acquired pneumonia who test positive for a respiratory virus. Moving forward, more collaboration with all stakeholders in the management of community-acquired pneumonia (from outpatient and urgent care/emergency providers to hospitalists and intensivists as well as pulmonary and infectious diseases consultants) is in order.
(Biebelberg et al. Clinical Infect Dis. Published online: Dec. 11, 2025.)