Antimicrobial stewardship in the UK during the COVID-19 pandemic: a population-based cohort study and interrupted time-series analysis

Abstract

Background. The COVID-19 pandemic has altered the context for antimicrobial stewardship in primary care. Aim: To assess the effect of the pandemic on antibiotic prescribing, accounting for changes in consultations for respiratory and urinary tract infections (RTIs/UTIs). Design and Setting: Population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) (January 2017 to September 2020). Method: Interrupted time series analysis evaluated changes in antibiotic prescribing and RTI/UTI consultations adjusting for age, gender, season and secular trends. We assessed the proportion of COVID-19 episodes associated with antibiotic prescribing. Results: There were 253,655 registered patients in 2017 and 232,218 in 2020 with 559,461 antibiotic prescriptions, 216,110 RTI consultations and 36,402 UTI consultations. Compared to pre-pandemic months, March 2020 was associated with higher prescribing (adjusted rate ratio 1.13; 95% confidence interval 1.11 to 1.16). Prescribing fell below predicted rates between April and August 2020, reaching a minimum in May (0.73, 0.71 to 0.75). Pandemic months were associated with lower rates of RTI/UTI consultations, particularly in April for RTIs (0.23; 0.22 to 0.25). There were small reductions in the proportion of RTI consultations with antibiotic prescribed and no reduction for UTIs. Among 25,889 COVID-19 patients, 2,942 (11%) had antibiotics within a COVID-19 episode. Conclusion: Pandemic months were initially associated with increased antibiotic prescribing which then fell below expected levels during the national lockdown. Findings are reassuring that antibiotic stewardship priorities have not been neglected due to COVID-19. Research is required into the effects of reduced RTI/UTI consultations on incidence of serious bacterial infection.

Impact of the COVID-19 pandemic on community antibiotic prescribing and stewardship: a qualitative interview study with general practitioners in England

“…Our findings are in line with the analysis showing when taking into account a decreased number of appointments, the number of prescriptions was 6.7% higher than expected (18). They are also supported by the analysis showing that March 2020 was associated with higher antibiotic prescribing, followed by lower rates than predicted between April and August 2020 (20), while the incidence of RTIs decreased (particularly in April 2020) (20,37). Although participants described having a 'lower threshold' for prescribing antibiotics (which may suggest that some were of little/no benefit), it is possible that these prescriptions were appropriate and influenced by patients' presentations (e.g., higher threshold for consulting, presenting later, access issues).…”

“…Studies from primary care in England have shown an overall decrease in antibiotic prescribing during 2020 compared to pre-pandemic (18)(19)(20)(21)(22)(23); with similar trends identified in Scotland (24), Northern Ireland (25) and other countries (26)(27)(28)(29). However, one study of UK data noted an initial increase in antibiotic prescribing in March 2020 before prescribing levels dropped below those expected (with the lowest rate in May) (20).…”

Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study

“…For the first pandemic wave, similar decreases in presentation and antibiotic prescribing for respiratory tract infections were found in a population-based cohort study in the UK, although in the UK, the initial increase in presentation was temporarily accompanied by an increase in antibiotic prescribing [ 16 ]. In Wales, the pandemic resulted in a significant reduction in dispenses of antibiotics commonly used for treatment of respiratory tract infection in the first wave, whereas dispensing of antibiotics primarily used for urinary tract and skin infections remained stable like in our study [ 17 ].…”

“…A prospective audit survey of consultation and management characteristics of patients with respiratory tract infections early in the first pandemic wave in 16 European countries showed that the proportion of patients prescribed antibiotics varied considerably between countries, and was generally lower during the pandemic as compared with the months before, except in Greece, Poland, and United Kingdom (UK) [15].…”

Changes in antibiotic prescribing following COVID‐19 restrictions: Lessons for post‐pandemic antibiotic stewardship

“…[1][2][3][4][5][6][7] In regions with high rates of SARS-CoV-2 infection, such as Europe and the United States, there have been reductions in community antibiotic prescribing following the introduction of COVID-19 restrictions in early 2020. [8][9][10][11][12][13][14] However, the underlying data are difficult to interpret as they reflect differing contributory and contemporaneous factors, including variation in public health restrictions and social policies, health care access, increasing use of telehealth and rates of SARS-CoV-2 infections.…”