New data from the Centers for Disease Control and Prevention (CDC) show a significant increase in antibiotic use in US hospitals early in the COVID-19 pandemic, with smaller upticks observed during subsequent COVID-19 surges.
The data, published yesterday in Clinical Infectious Diseases, confirm a trend that's been documented in both the United States and other parts of the world during the early months of the pandemic. Faced with severely ill patients with pneumonia-like illness, limited diagnostic tests and treatment options, and concerns about secondary bacterial infections, healthcare providers frequently turned to antibiotics.
But the study authors say that the smaller increases in antibiotic use observed in later COVID-19 waves highlight the need for hospitals to continue efforts to optimize antibiotic use and improve management of respiratory infections.
Dramatic increase in azithromycin use
The data come from 553 acute care hospitals that submitted inpatient antibiotic use (AU) data to the National Healthcare Safety Network from January 2019 to July 2022. For the study, a team of CDC researchers analyzed antibiotics administered via oral, parenteral, inhaled, and intramuscular routes. Researchers calculated monthly pooled AU rates for all antibiotics combined and for three specific antibiotic agents: azithromycin, ceftriaxone, and piperacillin with tazobactam.
Those three agents were selected because azithromycin and ceftriaxone are typically prescribed for community-acquired pneumonia and piperacillin with tazobactam is used for hospital-onset infections, which was one of the concerns with so many COVID-19 patients in intensive care units.
Lessons learned from the COVID-19 pandemic suggest that a continued focus on optimizing antibiotic stewardship efforts along with on-going work on improving the diagnosis and management of respiratory tract infections will help mitigate challenges with antibiotic use in future COVID-19 waves and, potentially, other pandemics.
Unsurprisingly, increases in pooled mean AU rates were observed for all antibiotics combined and each specific agent during the first COVID-19 wave. Compared with April 2019, the total AU rate in April 2020 for all antibiotics increased by 7%, with azithromycin use increasing by 64%, ceftriaxone by 27%, and piperacillin with tazobactam by 5%.
The authors note that the dramatic increase in azithromycin use likely reflects the early belief that azithromycin, used with the anti-malaria drug hydroxychloroquine, was a potentially effective treatment for COVID-19. Large-scale studies later showed, however, that azithromycin had no effect on disease severity.
After April 2020, AU rates for all antibiotics combined and for each of the specific agents declined as treatments and vaccines became available, antimicrobial stewardship efforts kicked in, and data showed that rates of secondary bacterial infections were low in COVID-19 patients. While rates of azithromycin and ceftriaxone use rose again during the Delta wave in November and December 2020 and the Omicron wave in the winter of 2022, the magnitude of the increase was smaller than that seen in April 2020, even though the later waves were larger.
"This analysis provides a broad perspective on hospital antibiotic use during the COVID-19 pandemic," the authors wrote. "Lessons learned from the COVID-19 pandemic suggest that a continued focus on optimizing antibiotic stewardship efforts along with on-going work on improving the diagnosis and management of respiratory tract infections will help mitigate challenges with antibiotic use in future COVID-19 waves and, potentially, other pandemics."