Has Progress Against Pandemic Also Improved Antibiotic Prescribing?

Increased respiratory viral testing for COVID-19 and Influenza could have contributed to improved antibiotic prescribing for respiratory symptoms.

Fewer antibiotic prescriptions were prescribed for respiratory symptoms during the pandemic than in the comparable pre-pandemic period, in a study of ambulatory clinic patients of the University of Wisconsin Health system in southern Wisconsin.

Alexander Lepak, MD, Assistant Professor, Infections Disease Faculty, University of Wisconsin School of Medicine and Public Health, Madison, WI, and colleagues found that while antibiotic prescribing rates increased during the pre-pandemic winter respiratory viral season, they decreased in the short-term and remained low throughout the corresponding pandemic period.

"One way to interpret the study is to draw a conclusion about how much inappropriate antibiotic use was occurring for respiratory viruses in the pre-pandemic period.But I think there is another side to this story, and that this is a huge success story " Lepak told Contagion.

"We had massive COVID-19 surges, with unprecedented numbers of patients with respiratory complaints, especially in the Fall between October and December, yet antibiotics were not prescribed, for the most part, in patients with respiratory complaints during this period--keeping in mind they had indistinguishable symptoms from other respiratory viruses where antibiotics were previously prescribed."

Lepak and colleagues—with whom, Lepak emphasized, the study was a "huge collaborative effort"—compared the number of antibiotic prescriptions provided at the more than 80 ambulatory clinic sites of UW Health with 7 million annual ambulatory encounters, in the pre-pandemic period of July 2018 to February 2020 and April 2020 to February 2021 during the pandemic.The number of ambulatory encounters during those periods were similar: 637,000 and 662,000 per month, respectively.

The Winter seasonal viruses, including influenza, respiratory syncytial virus (RSV) and seasonal coronavirus, demonstrated seasonal variation during the prepandemic but not the pandemic period.The number of patients presenting with seasonal viruses decreased from approximately 4800 per month prepandemic to 12 per month in the pandemic period.Other respiratory virus detections also decreased, from 560 per month prepandemic to 228 per month during the pandemic.

The investigators reported that, adjusting for seasonality, monthly antibiotic prescription for respiratory tract infections (the indication for antibiotic prescriptions is required by UW Health Pharmacy) fell 79%, from 10.5 to 2.2 prescriptions per 1000 patient encounters.

"Antibiotic prescribing for respiratory complaints was best correlated with activity of seasonal Coronaviruses, Rhinoviruses, RSV, metapneumovirus, etc, and it was not as well correlated with influenza and wasn't correlated at all with COVID-19 activity," Lepak commented."The difference between these is that we have accessible and timely diagnostics for the latter two, but not necessarily the former group, at least for ambulatory care patients.

"Based on these findings, our hypothesis is that providing more comprehensive reepiratory viral testing that is accessible and timely to ambulatory providers and patients may be able to significantly curb antibiotic prescribing for respiratory viruses," Lepak said.

Although the investigators found other studies which have showed relatively quick declines in rates of viral infections or antimicrobial prescribing, they characterize theirs as "the first to combine respiratory virus activity and antibiotic prescriptions that were indexed to the number of encounters over a prolonged period that includes the typical respiratory virus season."