July 16, 2024
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Antibiotic Usage During the COVID-19 Pandemic: Implications and Guidelines

With the emergence of multi-drug resistant microorganisms due to the overuse and misuse of antibiotics globally, the benefits of antibiotic usage are being threatened. To address this issue, antimicrobial stewardship principles have been introduced, focusing on responsible antibiotic prescribing. A recent study published in eClinical Medicine examines the application of these principles in antibiotic prescribing guidelines during the COVID-19 pandemic.

Global Impact of Antimicrobial Resistance

Annually, over 1.2 million people die from bacterial infections resistant to available antibiotics. Throughout the COVID-19 pandemic, antimicrobial resistance (AMR) has worsened as a result of high antibiotic usage, despite the fact that COVID-19 is caused by a virus. Previous research by the authors revealed that up to 60% of bacterial infections in COVID-19 patients were caused by resistant organisms. Therefore, evaluating pandemic-related guidelines on antibiotic prescribing becomes crucial.

Findings of the Study

The study analyzed 28 guidelines, providing 63 recommendations on antibiotic prescribing for COVID-19 across different languages and international sources. The guidelines were assessed using validated tools, and their characteristics were classified, including the composition of the panel and the presence of antimicrobial stewardship principles.

The analysis showed that over 80% of the guidelines addressed when and how to initiate antibiotics, while only about 20% provided guidance on antibiotic selection. Approximately 50% of the guidelines were of low quality, while 43% were of high quality. Infectious disease experts were represented on about 70% of the guideline panels, while public health experts were included in about 33% of the panels.

Over 70% of the guidelines incorporated some form of guidance on antimicrobial stewardship, with over a third mentioning judicious antibiotic prescribing. Around 40% of the guidelines discussed the potential for AMR during the pandemic, and over 50% included information on other antibiotic-associated harms. However, only one in seven guidelines included all three areas of antimicrobial stewardship.

Regarding the focus of the guidelines, over a third targeted all patients, 30% addressed antibiotic use in hospitalized patients, less than 10% discussed outpatient antibiotic use, and about 5% covered outpatients and non-ICU admitted patients. In terms of recommendations, about one in seven suggested empirical antibiotic use without considering evidence of bacterial infection, primarily for critically ill COVID-19 patients. Only one recommendation suggested treating all COVID-19 patients with standard antimicrobial protocols.

The importance of microbiological testing to exclude bacterial coinfection was emphasized in five out of six recommendations. Four guidelines recommended tapering or stopping antimicrobials based on microbiological findings after initiation.

Quality Improvement and Implications

The study highlights that many antibiotic prescribing guidelines are supported by low-certainty evidence, indicating a need for quality improvement. The researchers observed a positive correlation between guideline quality and the incorporation of antimicrobial stewardship principles. Guidelines developed with the involvement of infectious disease experts were 10% more likely to include these principles. Additionally, the presence of a public health expert or pharmacist on the panel increased the likelihood by up to a thousand-fold.

While the 2021 guidelines were 50% more likely to mention antimicrobial stewardship compared to those issued in 2020, the inclusion increased fourfold in the 2022 guidelines. Furthermore, guidelines evaluated with higher AGREE-REX scores were over three times more likely to incorporate antimicrobial stewardship.

The study emphasizes the need for better guidelines for the treatment of infectious diseases, especially considering the high rate of antibiotic prescription, particularly in non-critically ill COVID-19 patients documented during the pandemic. By improving guideline quality and incorporating antimicrobial stewardship principles, the appropriate and responsible use of antibiotics can be promoted, contributing to the global fight against antimicrobial resistance.


  1. Source: Coherent Market Insights, Public sources, Desk research
  2. We have leveraged AI tools to mine information and compile it