Antibiotic misuse during COVID underscores importance of stewardship programs, says CDC

The misuse of antibiotics during the COVID-19 pandemic points to a need for provider systems to shore up their antimicrobial stewardship programs, according to experts at the Centers for Disease Control & Prevention

A new research letter in JAMA Health Forum examined the use—or, rather, misuse—of antibiotics to treat COVID-19 for people enrolled in commercial health insurance plans. Researchers with the Children’s Hospital of Pittsburgh found that antibiotics were most prescribed for COVID-19 patients in emergency departments and in practice-based telemedicine consultations.

Kristin Ray, M.D., the corresponding author, told Fierce Healthcare in an email that “what we found was that antibiotics were sometimes prescribed for patients with COVID-19, despite no evidence that these treatments would improve outcomes.”

Kristin Ray
Kristin Ray, M.D. (Children's Hospital of Pittsburgh)

Lauri Hicks, the director of the CDC’s Office of Antibiotic Stewardship, and Sarah Kabbani, M.D., deputy in that office, told Fierce Healthcare in an email that “antibiotic use has been on a roller coaster ride that tracks with the waves of the pandemic. In the early months of the pandemic, healthcare providers were desperate to find options to treat patients. Many reached for antibiotics even though we know that antibiotics don’t treat viral illnesses like COVID-19.”

Hicks and Kabbani said that healthcare systems need to bolster their antimicrobial stewardship programs to limit misuse of antibiotics.

“To ensure antibiotics are being used appropriately even during a crisis, stewardship program activities must be appropriately resourced to continue that work,” they wrote. “Many pharmacists and physicians, who usually were responsible for antibiotic stewardship, had skills that were used for other roles during the pandemic response.”

They added that “some people develop a bacterial infection requiring antibiotics after having a viral infection, but that has been shown to be uncommon in people with COVID-19.”

The research letter found that azithromycin was the antibiotic prescribed the most, and the researchers said it may have been "selected for its potential anti-inflammatory and antiviral properties, especially before more data were available."

Hicks and Kabbani cited “unreliable reports" that the antibiotic was helpful to patients with COVID-19, leading to inappropriate use.

The research letter said that both adults and those aged 6 to 17 years most prescribed antibiotics at EDs and in practice-based telemedicine visits.

“Amoxicillin use among the youngest group suggests concerns about associated, but undiagnosed, bacterial infection such as otitis media or pneumonia,” the research letter said.

Lauri Hicks (Centers for Disease Control and Prevention)

Data were mined from 1,293,303 adult and 177,057 children outpatient visits in EDs, physician offices, practice-based telemedicine, direct-to-consumer telemedicine and urgent care centers between April 1, 2020, and May 31, 2022. Antibiotic use increased according to the age of the patients, 4% for children up to 5-years-old to 16% for adults from 45- to 64-years-old.

Acute respiratory tract infection possibly caused by COVID-19 accounted for 20% of visits, and 7% of ARTI-related antibiotic dispensing among all age groups. Four percent of antibiotic prescriptions for children and adolescents were dispensed within two days of visits and 5% within seven days.

For adults, 11% of antibiotic prescriptions were filled within two days of visits and 13% within seven days.

“Among children younger than 6 years, the most common antibiotic was amoxicillin (37%) followed by azithromycin (36%),” the research letter found. “In those aged 6 to 17 years and adults, azithromycin (68% and 70%) was more commonly received than amoxicillin (15% and 4%).”

Children and adolescents were more likely to seek treatment at physician offices than adults (66% vs 51%). The second most frequented destination for children and adolescents were EDs (12% vs 18% for adults), followed by practice-based telemedicine (11% vs 17% for adults).

The letter found that children under five were most likely to recieve antibiotics during a direct-to-consumer telehealth visit. Antibiotics were deployed most commonly in the Southern part of the U.S., according to the study.

Sarah Kabbani
Sarah Kabbani, M.D. (Centers for Disease Control and Prevention)

Amoxicillin was the antibiotic most prescribed to children 6 and younger, accounting for 37% of prescriptions, closely followed by azithromycin, which represented 36%. Those aged 6- to 17-years-old and adults were mostly prescribed azithromycin, accounting for 68% and 70% of prescriptions, respectively.

Amoxicillin accounted for 15% of prescriptions for people aged six to 17, and 4% of those for adults.

Misuse of antibiotics for COVID-19 has decreased, though it’s still a problem, according to the CDC.

“While we were seeing surges in COVID-19, during 2020 and 2021 social distancing and behaviors like handwashing and masking led to less spread of the garden variety infections,” said Hicks and Kabbani. “This led to an overall decrease in antibiotic use in the community. However, antibiotic prescribing for people with COVID-19 in outpatient settings, hospitals, and nursing homes is common and increases with each pandemic wave, most of which is unnecessary.”

COVID-19 also taught the importance of rapid diagnostic testing, they said.

“There is opportunity to better leverage diagnostic testing to inform whether antibiotics should be used or not,” wrote Hicks and Kabbani. “Reliably distinguishing between a viral infection that doesn’t warrant antibiotics, but may require other treatment, and a bacterial infection that will respond to treatment with antibiotics is a powerful tool. The pandemic also taught us about the importance of the skills that are leveraged to run antibiotic stewardship programs to improve antibiotic use.”

They added that patients and providers both can play a role when it comes to antibiotic stewardship.

“As a caregiver or patient, instead of asking for antibiotics for an illness, ask what can be done to feel better,” said Hicks and Kabbani. “As a healthcare professional, every patient interaction related to an infection is an opportunity to educate about the importance of appropriate antibiotic use.”