How were antibiotics used during the COVID-19 pandemic?

The overuse and misuse of antibiotics on a global scale threatens the benefits traditionally associated with antibiotic usage, as multi-drug resistant microorganisms continue to emerge. This led to the introduction of antimicrobial stewardship principles.

A new study recently published in eClinical Medicine explores the application of antimicrobial stewardship in the antibiotic prescribing guidelines during the recent coronavirus disease 2019 (COVID-19) pandemic.

Study: Antibiotic prescribing guideline recommendations in COVID-19: a systematic survey. Image Credit: Kateryna Kon/


Each year, over 1.2 million people worldwide die of bacterial infections that are resistant to available antibiotics. Antimicrobial resistance (AMR) has been exacerbated throughout the COVID-19 pandemics, as a high rate of patients with COVID-19 received antibiotics, despite the fact that COVID-19 is caused by a virus

Previous research by the authors of the current study revealed that among COVID-19 patients with simultaneous bacterial infection, up to 60% were due to resistant organisms. AMR has risen throughout the pandemic, which led to the current attempt to evaluate pandemic-related guidelines on antibiotic prescribing.

What did the study show?

The researchers included guidelines for antibacterial therapy in COVID-19 across all languages and from international sources. Each set was independently assessed using validated tools. All guidelines were classified according to certain characteristics such as panel composition and the presence of antimicrobial stewardship principles. 

A total of 28 guidelines that provided 63 recommendations on antibiotic prescribing were included in the analysis. While over 80% of guidelines examined when and how to begin antibiotics, about 20% provided guidance on antibiotic selection.

About 50% of the guidelines were of low quality, while 43% were of high quality. Infectious disease experts were represented on the guideline panel in about 70% of guidelines, whereas about 33% of panels included a public health expert.

Over 70% included guidance on antimicrobial stewardship in at least one area. Over a third mentioned judicious antibiotic prescribing or antimicrobial stewardship.

Over 40% of guidelines discussed the potential for AMR in the pandemic. Furthermore, over 50% of the guidelines incorporated information on other antibiotic-associated harms, such as adverse effects. 

Only about one in seven of the guidelines included all three of these areas of antimicrobial stewardship. About 80% described antibiotic use in general, whereas 20% explored azithromycin use during COVID-19.

Over a third of guidelines focused on all patients, while 30% explored antibiotic use in hospitalized patients. Less 10% discussed outpatient antibiotic use, whereas about 5% described outpatients and inpatients not admitted to the intensive care unit (ICU) or with children.

About one in seven recommendations suggested empirical antibiotic use without regard to evidence of bacterial infection. These were directed mostly at critically ill COVID-19 patients. Only one recommendation indicated that all COVID-19 patients should be treated with the standard antimicrobial protocol.

Five out of six recommendations emphasized the importance of microbiological testing to exclude bacterial coinfection. Four guidelines recommended that following initiation, antimicrobials should be tapered or stopped depending on the microbiological findings.

Among the recommendations on overall antibiotic use, most were strong or conditional, whereas those for azithromycin use were mostly strong. However, the evidence for these recommendations was often low.

If guidelines are produced with the help of infectious disease experts, the likelihood that they will incorporate antimicrobial stewardship principles is increased by about 10%. With the presence of a public health expert or pharmacist on the panel, this likelihood is further increased by five-fold to over a thousand-fold.

With better guideline quality, the likliehood of including this concept rose by almost nine-fold. While the 2021 guidelines were 50% more likely to mention these principles than those issued in 2020, the likliehood increased by fourfold in the 2022 guidelines.

If the guidelines are evaluated by the AGREE-REX score, every increase in score of 10% increases the likliehood that antimicrobial stewardship will be incorporated by over three-fold. Specific guideline and recommendation domains were associated with a better chance that these principles would be mentioned.

What are the implications?

Most antibiotic prescribing guidelines are supported by low-certainty evidence, thus indicating the need for quality improvement. The higher the quality of the guidelines, the more likely they were to incorporate antimicrobial stewardship principles.

While few guidelines recommend antibiotic therapy for non-critically ill patients, some advised the empiric initiation of antibiotics in critically ill patients. However, the high rate of antibiotic prescription for other COVID-19 patients, especially at the community level documented during the pandemic, demonstrates the urgent need to evolve better guidelines for the treatment of infectious diseases.

Journal reference:
  • Langford, B. J., Leung, V., Lo, J., et al. (2023). Antibiotic prescribing guideline recommendations in COVID-19: a systematic survey. eClinical Medicine. doi:10.1016/j.eclinm.2023.102257.
Dr. Liji Thomas

Written by

Dr. Liji Thomas

Dr. Liji Thomas is an OB-GYN, who graduated from the Government Medical College, University of Calicut, Kerala, in 2001. Liji practiced as a full-time consultant in obstetrics/gynecology in a private hospital for a few years following her graduation. She has counseled hundreds of patients facing issues from pregnancy-related problems and infertility, and has been in charge of over 2,000 deliveries, striving always to achieve a normal delivery rather than operative.


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