Acute Pneumonia and the Hidden Effect of Antibiotics

Klepikov I

Published on: 2021-10-24


The history of treatment of acute pneumonia (AP) is divided into two fundamentally different periods. Initially, for many centuries, medicine accumulated information about the methods of treating this disease, which was scrupulously obtained empirically. The constructiveness of these searches was very difficult and limited due to a lack of scientific information and insufficient technical support for clinical trials and research. Nevertheless, for a long period of time, there was a certain trend in the set of means of providing assistance to this category of patients.


acute pneumonia; sterilizing; azithromycin; antibiotics alone

Opinion and Perspective

The second period of this history began in the middle of the last century after the discovery of antibiotics and completely changed the principles of AP treatment. The success of antibacterial therapy began to form the idea that medicine has received a universal and effective treatment. The centuries-old experience of helping these patients was no longer taken into account, and the previous methods were discarded. In this situation, there was no room for a critical and balanced forecast of the long-term consequences of such "sterilizing" therapy. For a long time, the main treatment of AP was defined by the term "antibiotics alone". The short-sightedness of such a strategy became more and more obvious every year, but the desire to restore the former effectiveness of antibacterial therapy prevailed over a reasonable and balanced analysis of the natural biological consequences of this drug intervention.

Over time, the use of antibiotics and their effect on the microflora that accompanies our body has significantly expanded not only as a result of medical prescriptions. For example, many people know about the use of these drugs in such branches of the food industry as animal husbandry, poultry farming and even fishing. In this regard, many countries have adopted laws and regulations that oblige manufacturers to provide information about the use of these medicines in the production of the final product (Figure). The widespread and long-term use of antibiotics could not remain without biological consequences, which continue to progress slowly but steadily.

Figure: Food packaging with information about the use of antibiotics in the production process.

The worldview on the problem of AP, which has developed over the past few decades, proclaims concepts and ideas that do not correspond to the basics of medical science and the objective facts of the surrounding reality. But, since the AP concept is the key to solving the problem and the actual guide to finding optimal ways, the significance of the didactic consequences of the long-term priority of antibiotics seems to be the main barrier that no one has yet overcome. The leading provisions of the modern AP doctrine are accepted in medical circles as indisputable, despite the presence of new and new counterarguments.

Has anyone written that long-term dependence on antibiotics in the treatment of AP forced us to consider the microbial factor as the main cause of the disease, and the inflammatory process in the lungs, which has never been contagious, to be attributed to infectious nosologies? For many years, the main task in the treatment of AP was considered to be the accurate diagnosis of its pathogen and its targeted suppression. The failure of these efforts has become apparent only recently, although the general medical principles have not changed [1,2].

At the same time, the concentration of attention on this narrow direction prevented the manifestation of due interest in the steady growth of viral forms of AP [3-5]. In addition, if we take into account the main biological effect of antibiotics, it is quite reasonable to imagine their role in disrupting the proportions of the microcosm around us and increasing the proportion of viruses among the pathogens of inflammatory processes. It takes time to confirm this postulate, but even now the events of the last decades are quite convincing in favor of this version.

For example, the SARS-CoV-2 pandemic, which is presented in expert assessments as a sudden catastrophe, may well be considered from a different point of view as the result of a long-term suppression of microbial representatives of our microbiota and the environment through the widespread use of antibiotics. This phenomenon, judging by the sequence of events, should at least have been expected. What suddenness can we talk about if the development of the pandemic was preceded by two major epidemics of coronavirus infection (SARS, MERS), the experience of which did not lead to the emergence of new fundamental decisions in providing care to these patients. Almost twenty years have passed since the first such epidemic. This is a significant period of time during which the trend towards severe epidemics of influenza and other viral respiratory diseases continued to increase. However, all these years, the strategy for solving the problem of AP continued to be determined by the leading role of pathogens in the development of the disease and the primacy of antibiotics in treatment.

The peculiarities of antibiotics that have only an antibacterial effect and do not affect the vital links of pathogenesis do not allow us to consider them as the leading and even more so the only means of treating AP. At present, when there are a large number of patients with COVID-19 pneumonia, in whom antibiotics have lost their therapeutic value, it would seem that the time has come for a radical revision of the ideas about many important aspects of AP and bringing the views in line with fundamental scientific materials and facts.

The instructive nature of the current pandemic is manifested in a number of new circumstances that should become an incentive for revising the previous stereotypes of treating patients with acute inflammatory processes of the lungs.      First, the hope for the usual leading role of antibiotics in the treatment of a new type of AP has disappeared.

Secondly, bacterial forms of AP, despite their interpretation in recent years as an infectious disease, were not subjected to isolation and other anti-epidemic measures during hospitalization. Now, the ease of the spread of the coronavirus and the uncertainty of successful treatment force such patients to concentrate in specialized closed departments for this purpose. Such a concentration of severe and extremely severe patients with one disease increases the possibility of a broad professional assessment of the dynamics of the process and the corresponding conclusions. However, so far, work in the coronavirus control units only carries a heavy moral burden on the service personnel [6-9].

Third, statistics inexorably indicate that the loss of the target role of antibiotics in the treatment complex did not significantly affect the results. Thus, among those infected with coronavirus, only 20% need hospitalization and medical care. The remaining 80% tolerate such contact in a mild form, and many people only find out about it through tests [10-13]. The mortality rate among patients with COVID-19 pneumonia also did not increase compared to this indicator among hospitalizations with community-acquired pneumonia [14-20].

These facts give an unambiguous hint that the pathogen of AP is not the main cause of the disease, and etiotropic treatment does not significantly affect the final results. The logic of current events indicates the need to revise the current concept of the AP, starting with its main provisions. The most important information for such a revision is the anatomical and functional feature of the lungs, which allows us to understand why the mechanisms of development of general circulatory disorders in inflammation of the lung tissue have an effect opposite to the influence of inflammatory foci on the periphery, but which is mostly ignored.

However, the facts of reality indicate that the desire to preserve antibiotic therapy as the leading type of treatment, despite the changed conditions, prevails over logic and meaning. According to the available information, the absence of the need to use antibiotics against a viral infection does not prevent their appointment.

For example, bacterial infection, the methods of determining which for many years have caused great doubts about their reliability, is detected only in a few percent of cases among patients with COVID-19 pneumonia. At the same time, antibiotic treatment is carried out in more than 70-80% of these patients [21-24]. Sometimes the old stereotypes of providing medical care in the new conditions are not revised at all, and patients with coronavirus infection are automatically included in the treatment regimen for community-acquired pneumonia [25,26]. However, it is no secret that the main emphasis in such treatment regimens is on antibiotics.

But not only has the practical implementation of medical care in the context of a pandemic not undergone the necessary correction. The monopoly of old ideas remains a big obstacle when conducting new research on the problem raised. For example, the antibiotic "azithromycin" has been used in medicine for more than 30 years not only for bacterial forms of AP, but also for middle ear inflammation, streptococcal pharyngitis and even diarrhea [27]. Currently, this drug, which does not have proven antiviral activity, is undergoing clinical trials against the coronavirus. Only the inviolability of the previous doctrine of the disease, which was formed as a result of excessive evaluation of antibiotics, can explain the fact that, having received no evidence of the beneficial effect of azithromycin against coronavirus, the authors propose to continue this study [28].

Antibiotics are still one of the most popular medicines. Their action, unlike other representatives of the pharmacopoeia, is directed not at the structures and substances of the body, but at its microflora. At the same time, each representative of the microbial world is itself a separate biological object. It is these circumstances that can explain the fact that the same antibiotic can help as a general therapeutic agent for diseases that are completely incomparable in pathogenesis. However, with such a narrowly focused "sterilizing" therapy, even if it is effective, the elimination of functional and morphological disorders remains completely a problem of the body itself.

The era of the use of antibiotics in medicine has brought not only the salvation of many human lives, but also the side effects of this therapy. The antibiotic-resistant transformation of the microflora and the need to develop new more effective medicines have especially increased in the last 2-3 decades. The biological consequences of the widespread use of antibiotics have already passed the point of no return. They should be perceived as a persistent phenomenon that will continue to develop, and this trend can only be slowed down a little by introducing much stricter measures for the prescription and use of antibiotics. At the same time, the growing role of viruses in our environment is becoming more and more obvious, which requires awareness and appropriate correction of medical strategies.

However, despite the colossal biological effects, they represent only the tip of the iceberg of the general problem of the side effect of antibiotics. To understand the depth and significance of these consequences, as well as to develop fundamental plans for future research and implement effective solutions, it is necessary, first of all, to realize and eliminate the negative didactic influence of this type of therapy on the formation of a professional worldview. The narrowness of existing ideas about the nature of AP is becoming more and more obvious every year as an obstacle to achieving the desired goals. This is the only consequence of antibiotics that can be corrected, and its correction completely depends on each of us.


  1. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. on behalf of the American Thoracic Society and Infectious Diseases Society of America. “Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America”. American Journal of Respiratory and Critical Care Medicine. 2019; 200: e45-e67.
  2. Peyrani P, Mandell L, Torres A, Tillotson GS. The burden of community-acquired bacterial pneumonia in the era of antibiotic resistance, Expert Review of Respiratory Medicine. 2019; 13: 139-152.
  3. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008; 86: 408–416.
  4. WHO Revised global burden of disease 2002 estimates. 2004.
  5. Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. "Viral pneumonia". Lancet. 2011; 377: 1264–1275.
  6. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020; 3:e203976-e203976.
  7. Leiter RE. Reentry. NEJM. 2020.
  8. Rosenquist JN. The Stress of Bayesian Medicine - Uncomfortable Uncertainty in the Face of Covid-19. N Engl J Med. 2021; 384: 7-9.
  9. Erdem H, Lucey DR. Healthcare worker infections and deaths due to COVID-19: a survey from 37 nations and a call for WHO to post national data on their website. Int J Infect Dis. 2021; 102: 239-241.
  10. Keeley AJ, Evans CM, de Silva TI. Asymptomatic SARS-CoV-2 infection: the tip or the iceberg? Thorax. 2020; 75: 621-622.
  11. Ing AJ, Cocks C, Green JP. COVID-19: in the footsteps of Ernest Shackleton. Thorax. 2020; 75: 693-694.
  12. Wu Z, McGoogan JM. Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China. Summary of a Report of 72?314 Cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020; 323: 1239-1242.
  13. Ra SH, Lim JS, Kim G, Kim MJ, Jung J, Kim S-H, et al. Upper respiratory viral load in asymptomatic individuals and mildly symptomatic patients with SARS-CoV-2 infection. Thorax, 2021; 76: 61-63.
  14. Kim JW, Kim JJ, Yang HJ, Lim YS, Cho JS, Hwang IC, et al. The Prognostic Factors of Pneumonia with Septic Shock in Patients Presenting to the Emergency Department. Korean Journal of Critical Care Medicine 2015; 30: 258-264.
  15. Jason P, Dean NC, Guo Q, Kuan WS, Lim HF, Lim TK et al. Severe community-acquired pneumonia: timely management measures in the first 24 hours. Critical Care. 2016; 20: 237.
  16. Vidal A, Santos L. Comorbidities impact on the prognosis of severe acute community-acquired pneumonia. Porto Biomedical Journal. 2017; 2: 247-346.
  17. Ceccato A, Torres A. Sepsis and community-acquired pneumonia. Ann Res Hosp. 2018; 2:7.
  18. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020; 323:1574-1581.
  19. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online. 2020.
  20. Gupta S, Wang W, Hayek SS, Chan L, Mathews KS, Melamed ML, et al. Association between early treatment with tocilizumab and mortality among critically ill patients with COVID-19. JAMA Intern Med. 2020; 80:1436-1446.
  21. Beovic B, Dousak M, Ferreira-Coimbra J, Nadrah K, Rubulotta F, Belliato M, Berger-Estilita J, et al. Antibiotic use in patients with COVID-19: a ‘snapshot’ Infectious Diseases International Research Initiative (ID-IRI) survey. Journal of Antimicrobial Chemotherapy. 2020; 75: 3386–3390.
  22. Kim D, Quinn J, Pinsky B, Shah NH, Brown I. Rates of co-infection between SARS-CoV-2 and other respiratory pathogens. JAMA 2020; 323: 2085-2086.
  23. Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Holmes A, et al. Bacterial and fungal co-infection in individuals with coronavirus: A rapid review to support COVID-19 antimicrobial prescribing . Clin Infect Dis. 2020; 71: 2459–2468.
  24. Puzniak L, Finelli L, Yu KC, Bauer KA, Mosie P, De Anda C, et al. A multicenter analysis of the clinical microbiology and antimicrobial usage in hospitalized patients in the US with or without COVID-19. BMC Infect Dis. 2021; 21: 227.
  25. Heneghan C, Pluddemann A, Mahtani KR. Differentiating viral from bacterial pneumonia. The Centre for Evidence-Based Medicine. Evidence Service to support the COVID-19 response. University of Oxford. 2020.
  26. Lipman M, Chambers RC, Singer M, Brown JS. SARS-CoV-2 pandemic: clinical picture of COVID-19 and implications for research. Thorax. 2020; 75: 614-616.
  28. Gyselinck I, Janssens W, Verhamme P, Vos R. Rationale for azithromycin in COVID-19: an overview of existing evidence. BMJ, Open Respiratory Research. 2021; 8: e000806.