Trends in Antibiotic Prescribing in Out-of-Hours Primary Care in England from January 2016 to June 2020 to Understand Behaviours during the First Wave of COVID-19

Abstract

We describe the trend of antibiotic prescribing in out-of-hours (OOH) general practices (GP) before and during England’s first wave of the COVID-19 pandemic. We analysed practice-level prescribing records between January 2016 to June 2020 to report the trends for the total prescribing volume, prescribing of broad-spectrum antibiotics and key agents included in the national Quality Premium. We performed a time-series analysis to detect measurable changes in the prescribing volume associated with COVID-19. Before COVID-19, the total prescribing volume and the percentage of broad-spectrum antibiotics continued to decrease in-hours (IH). The prescribing of broad-spectrum antibiotics was higher in OOH (OOH: 10.1%, IH: 8.7%), but a consistent decrease in the trimethoprim-to-nitrofurantoin ratio was observed OOH. The OOH antibiotic prescribing volume diverged from the historical trend in March 2020 and started to decrease by 5088 items per month. Broad-spectrum antibiotic prescribing started to increase in OOH and IH. In OOH, co-amoxiclav and doxycycline peaked in March to May in 2020, which was out of sync with seasonality peaks (Winter) in previous years. While this increase might be explained by the implementation of the national guideline to use co-amoxiclav and doxycycline to manage pneumonia in the community during COVID-19, further investigation is required to see whether the observed reduction in OOH antibiotic prescribing persists and how this reduction might influence antimicrobial resistance and patient outcomes.

Antibiotic Prescribing Trends in Belgian Out-of-Hours Primary Care during the COVID-19 Pandemic: Observational Study Using Routinely Collected Health Data

“…A study in Iceland showed that there was an increase in the total number of medication prescriptions; however, the number of antibiotic prescriptions remained stable [ 36 ]. English data from primary care showed that the prescribing of antibiotics decreased significantly [ 37 , 38 ] and also, data specifically from OOH care showed a reduction in antibiotic prescribing during the first wave of COVID-19 [ 39 ]. However, when looking at the number of prescriptions per contact, during the first months of the pandemic, there is a significant increase, possibly explained by an increase in inappropriate antibiotic use in telephone consultations [ 40 ].…”

The Pandemic beyond the Pandemic: A Scoping Review on the Social Relationships between COVID-19 and Antimicrobial Resistance

“…Literature reports great concern among healthcare workers regarding excessive prescription rates, the use of broad-spectrum antibiotics, prolonged antibiotic treatments without clinical justification, and inappropriate prescribing of antibiotics to patients infected with COVID-19 [7][8][9][10][11][12]. For example, in the United Kingdom, Zhu et al found that clinicians prescribed more broad-spectrum antibiotics due to the inability to assess patients face-to-face [13]. In Spain, Abelenda-Alonso et al found that before the pandemic, the antibiotic consumption in January and February 2019, compared with the same months in 2020, was similar.…”

“…Second, the behavioural interventions to prevent the spread of COVID-19 infection, which includes physical barriers and social distancing, likely also mitigate the increase of other kinds of infections, including bacterial, diminishing, as a consequence, antimicrobial use [9]. In addition, due to self-isolation and the avoidance of the health services because of the lockdowns and the fear of COVID-19 exposure, there was a decreased demand for necessary antimicrobials and on antibiotic prescription in emergency rooms and day clinics [13,15,16]. On the negative side, impacted by overcrowded health services and overburdened clinicians, consultation time is minimal due to the increase in patient numbers, negatively affecting clinician-patient communication, impairing the information and education that the patients receive on proper antibiotic usage [18].…”

Impact of the COVID-19 Pandemic on Community Antibiotic Prescribing and Stewardship: A Qualitative Interview Study with General Practitioners in England

“…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 on 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 ].…”