Dr. Sax: For years, we’ve heard that finishing the entire round of antibiotics is necessary to prevent becoming resistant to the drug. It turns out that just the opposite is true. Emerging literature on antibiotic treatments show emphatically that shorter courses are clearly associated with fewer side effects and less resistance; the longer the course, the more resistant people become to the drug. A decent strategy is to start taking antibiotics for the number of days prescribed, and if you feel completely well before finishing them, stop early.

Note: Please check with your doctor for individual guidance before stopping antibiotic treatment.

2.     Is Covid going away or will cases spike again this winter?

Dr. Sax: A surge in Covid-19 cases is likely to occur over the next 4 to 8 weeks. Unlike influenza, Covid circulates year-round, with rises in the summer and during the respiratory virus season. Omicron has stayed with us, mutating into multiple variants instead of a single one. The good news however is that because of widespread immunity – 99% of the population has seen the virus due to infection and/or vaccination – Covid cases are much less severe than before.

3.     What are the best treatments now available for high-risk patients with Covid?

 Dr. Sax: Paxlovid is still the treatment of choice. Antiviral alternatives include remdesivir, which is well tolerated, and unlike Paxlovid, has few interactions with other drugs and no rebound effect (see q. 4), but it is available only via an IV infusion; and molnupiravir, which has lower efficacy rates and is not recommended for people of reproductive age. Note that monoclonal antibodies, once favored as game-changing treatments for Covid, are ineffective against any of the current Omicron variants.

For now, the first-line therapy remains Paxlovid, a combination of two protease inhibitors (drugs used to treat viral infections) started within 5 days of symptoms appearing and taken twice daily orally for 5 days. Paxlovid has some issues, most notably the rebound effect and interactions with other drugs, but it’s the most accessible and effective treatment we have right now to reduce severe outcomes in high-risk patients (older people, especially with obesity, diabetes, chronic kidney disease, COPD, neurocognitive disorders or heart disease). Low risk, immunized patients who get Covid may want to wait a few days if not feverish or symptomatic…hopefully you will have a mild case that won’t require any drugs at all.

4.     Is the Paxlovid rebound – a recurrence of Covid symptoms after completing the course of therapy – more common than previously reported? 

Dr. Sax: Yes, it occurs in 20 to 30% of patients taking the drug, which is significantly higher than we initially thought. One reason is that the optimal duration and start of Paxlovid treatment has not been determined. We prescribe it for 5 days, but would it be better if taken for 7 to 10 days, or perhaps not taking it immediately after symptoms start? We just don’t know the answers yet. We do know that while symptoms are generally milder during the rebound, you are infectious again and should go back to isolating. And to clear up a common misconception, we don’t know yet if taking Paxlovid prolongs shedding of the virus, or whether people who experience rebound would have had a long course of viral shedding to begin with.

5.     What other Covid treatments are in the wings?

 Dr. Sax: A number of promising treatments are being studied. The antiviral pill ensitrelvir, approved in Japan but not yet by the FDA, doesn’t appear to cause the rebound effect of Paxlovid, shortens the duration of symptoms like loss of smell and taste, and reduces the incidence of Long Covid in patients treated early on. Additionally, two oral versions of remdesivir are in clinical trials.

A study repurposing metformin, commonly used to manage diabetes, has reported very encouraging data for treating mild to moderate Covid and reducing the incidence of Long Covid. The national clinical trial, ACTIV-6, is ongoing and easy to participate in from home. Newly diagnosed patients can enroll online at ACTIV-6study.org; receive the drug or placebo and a pulse oximeter by mail; and check in periodically online or by phone for 14 days. For more information on the metformin ACTIV-6 study: https://activ6study.org/

6.     Is Long Covid on the wane?

 Dr. Sax: Thankfully, yes. As the severity of disease, associated with a high risk of developing Long Covid, continues to diminish, so does the incidence of Long Covid. A number of treatments are being used successfully to alleviate the symptoms. These include physical pacing which has helped people with chronic fatigue syndrome, post-concussion protocols for cognitive difficulties, low doses of aripiprazole for brain fog, anticoagulants for abnormal clotting, and probiotics for gastrointestinal issues. The condition is still being studied to determine the cause as we’re not certain if it is triggered by an active virus or if remnants of the infection cause an abnormal immune response.

7.     What have we learned about Covid testing that can help ensure dependable results?

 Dr. Sax: New research shows the most accurate time to test for Covid is on the fourth day of having symptoms, when viral loads (amount of virus replicating in your body) peak.  This is markedly different from the beginning of the pandemic, when viral loads peaked earlier, either just before or on day one of illness. Our immune systems have been primed to react to Covid, making pre-symptomatic contagiousness much less common now.

It’s also important to remember that very few false positives occur with Covid testing. If you don’t have many symptoms and test positive, it’s probably not allergies or the flu, it’s Covid, and you’re infectious. But if you’re symptomatic and test negative, is it safe to attend a social event? In general, I discourage anyone with a severe or bad respiratory viral infections from doing so, and that’s especially true if you’re going to be socializing with other people who might be at risk for severe disease.

8.     Who should get the Covid XBB monovalent booster that was made available to everyone in the fall? Is it safe to wait, or not get the booster at all?

 Dr. Sax: While the CDC recommended the booster for anyone 6 months and older, there is some uncertainty about how essential it is for the entire population, given the significant decrease in disease severity. Based on current knowledge, I’d prioritize it for certain patients and not others. We know that older patients are at highest risk for Covid complications, even if previously vaccinated, as well as younger people with underlying conditions such as diabetes, asthma or obesity. These groups would benefit most from getting the XBB booster to protect against severe disease from variants circulating now. So for example, I would strongly recommend the booster for an 89-year-old patient with no significant medical problems, who was never diagnosed with Covid, and received her fourth dose of the vaccine last fall; and generally recommend the booster for a 44-year-old woman with diabetes and obesity who received 3 prior vaccine doses, or a 25-year-old man with asthma who has been vaccinated several times previously.

But for healthy people who have hybrid immunity – a combination of immunizations and a past bout with Covid that is considered the best protection – there is no data showing additional vaccines are beneficial. Questions have also been raised regarding the need for young people and children to get an annual Covid booster, especially if they’ve had the virus previously.

9.     What are your recommendations regarding the new Respiratory Syncytial Virus (RSV) vaccine?

 Dr. Sax: RSV, a disease that can severely impact people at both extremes of the age spectrum, returned with a vengeance last year…it’s very good news that we finally have a vaccine. In infants, it can cause pauses in breathing, which is terrifying for their parents to see. In older adults, and in people with multiple medical issues, it can lead to serious illness and hospitalization. I recommend the RSV vaccine for people with chronic lung disease, immune compromised, or have hematologic, neurologic, kidney, liver, endocrine disorders; and for people over 70, even if they have no medical problems. In fact, it’s what I recommended to my mother, a healthy 89-year-old. For healthy people in their 60s, it’s less clear cut, and should be a matter of choice after discussing the risks and benefits with your doctor.

Two RSV vaccines have been approved for people over 60: Arexvy, and Abryzvo, which is also approved for women in the latter part of their pregnancy, to protect themselves and their babies. The optimal time to get the vaccine is before the respiratory virus season, but still good through January. Although you can get it at the same time as the flu or Covid vaccine, I strongly recommend that you don’t. Because it’s new, get the RSV vaccine separately so that any unanticipated side effects can be easily sorted out.

10. Is the shingles vaccine (Shingrix) necessary? Is it effective?

 Dr. Sax: This is one of the most underused but absolutely essential vaccines. I urge everyone over 50, or the immunocompromised of any age, to get the Shingrix vaccine. It will protect you against herpes zoster, a common and potentially very serious illness that can leave you with chronic pain, called postherpetic neuralgia (PHN), or cause complications that devastate the eyes. Shingrix is much better than earlier vaccines because it not only helps prevent shingles but reduces the severity of illness and incidence of PHN in people with breakthrough cases. Two doses are needed, 2 to 6 months apart. Note that the vaccine is potent enough to provide protection even if the second dose is received a year or more later; there is no need to restart the series.

Learn more:

Immunize.org, featuring an Ask the Experts section for healthcare professionals

Covid-19 Drug interaction checker

CDC