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It is not uncommon to consider corticosteroids at this stage, because of their anti-inflammatory effects. Corticosteroids were widely used during the 2002-3 SARS outbreak. However, in a subsequent systematic review, including 29 low-quality studies of steroid use, 25 studies were inconclusive and four reported possible harm from steroid use.

A further evidence review did not support corticosteroid treatment, reporting no evidence of net benefit with corticosteroids in “respiratory infection due to RSV, influenza, SARS-CoV, or MERS-CoV”, and that corticosteroids probably impair clearance of SARS-CoV.

In contrast to pneumonia, corticosteroids show much clearer benefit in patients with sepsis. Potential harms of rapid deployment of antibiotics for pneumonia The main disadvantage of this proposed strategy is that it would tend to drive increased bacterial resistance. However, in a pandemic with a high mortality rate in a specific subpopulation, in this case very elderly people, this needs to be weighed against the benefits of the policy.

Apart from penicillin allergy, adverse reactions to the recommended antibiotics, e.g. Conclusions Interventions that affect mortality in pneumonia are of great significance for public health, particularly during the current pandemic. Rescue prescribing strategies, initiated by the patient at an early stage, could aid effective delivery of antimicrobials, significantly reduce hospital admissions, and reduce mortality.

While reducing antimicrobial resistance should remain a

global

current

Rapid interventions like this could be life-saving. A UK strategy of suppression including 14-day isolation for households with symptoms.

In this context, equipping patients with rescue antibiotics may be a legitimate strategy to consider. Strategies should also plan to ensure that all those eligible at risk, eg COPD and immuno-compromised as well as the elderly, were up to date with preventive immunisation (influenza and pneumococcal). And also consider rescue medication for those aged 70 or older (regardless of medical conditions), and under 70 with an underlying health condition instructed to get a flu jab as an adult each year on medical grounds.

In patients with few physiological reserves, there is no room for error, and providing the right initial treatment, and rapidly, matters. Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health.

The views are not a substitute for professional medical advice.

We welcome feedback on this page and if there are errors or omissions then please let us know at cebm@phc.ox.ac.uk.

Please note there was an error with the prescribing strategy the original version stated doxycycline plus clarithromycin, which is incorrect.

The article should have stated doxycycline or clarithromycin as per NICE recommendations. Please Check NICE guidance for

all

‘Alternatively, if there is a penicillin allergy, or amoxicillin is unsuitable (for example atypical pathogens are suspected) options are oral doxycycline 200 mg on the first day then 100 mg once a day for 4 days (total course of 5 days), or oral clarithromycin 500 mg twice a day for 5 days, or oral erythromycin (in pregnancy) 500 mg four times a day for 5 days.’ Authors. Carl Heneghan is the Editor in Chief BMJ EBM, Professor of Evidence-Based Medicine, Director of the Centre for Evidence-Based Medicine and Director of Studies

for

(Full bio and disclosure statement here) Jeffrey K.

Aronson is a physician and clinical pharmacologist working in the Centre for Evidence-Based Medicine in the Nuffield Department of Primary Care Health Sciences, University of Oxford.

He is an Associate Editor of BMJ EBM and a President Emeritus of the British Pharmacological Society. Richard Hobbs is a GP and Nuffield Professor of Primary Care Health Sciences, Director, NIHR English School for Primary Care Research and Director, NIHR Applied Research Collaboration (

NIHR