Antibiotic Prescribing and Stewardship During COVID-19

Melinda Neuhauser, PharmD; Sarah Kabbani, MD, MSc; Sharon Tsay, MD


October 19, 2021

Editorial Collaboration

Medscape &

The COVID-19 pandemic has presented both challenges and opportunities. Antibiotic stewardship is a set of commitments and actions to optimize the treatment of infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance. The Centers for Disease Control and Prevention (CDC) has published several studies characterizing antibiotic use during the COVID-19 pandemic in outpatient, nursing home, and hospital settings. Findings from these studies inform opportunities to improve antibiotic use and guide the development of resources to support healthcare professionals and health systems.

Here are five key things to know about antibiotic prescribing and stewardship during the COVID-19 pandemic.

1. Antibiotic use during the COVID-19 pandemic varied across healthcare settings, but azithromycin prescribing was higher than expected.

In outpatient settings, there was a significant decline in antibiotic prescribing, probably reflecting several factors, including changes in healthcare utilization and decreases in transmission of viral respiratory infections for which antibiotics are often inappropriately prescribed.[1] However, early in the pandemic there was a relative increase in azithromycin prescribing in states with higher COVID-19 incidence, and prescribing remained higher than expected during the peak of COVID-19 cases in winter of 2020.[2]

In nursing homes, overall antibiotic prescribing also declined, which may be attributed to changes in the resident population during the pandemic and improved implementation of infection prevention and control measures. There was increased prescribing of azithromycin and other antibiotics, such as ceftriaxone, that are commonly used for lower respiratory infections.[2]

In hospitals, almost 80% of inpatients with COVID-19 received antibiotics, and approximately half of patients received ceftriaxone, commonly in combination with azithromycin. Increases in the use of azithromycin and ceftriaxone in both hospitals and nursing homes corresponded to spikes in COVID-19 activity.[3]

2. Secondary bacterial infections are uncommon in patients with COVID-19 at the time of hospital admission.

Secondary bacterial infections appear to be less common in patients with COVID-19 than in patients with influenza. A meta-analysis estimated that a co-bacterial infection was identified in 6.9% (95% CI, 4.3%-9.5%) of patients with COVID-19, and only 3.5% (95% CI, 0.4%-6.7%) of patients on initial presentation.[4] Subsequently, a multicenter study found that bacterial respiratory co-infections were uncommon (1.2%) at the time of hospital admission.[5] Because secondary bacterial infections are uncommon in patients with COVID-19, the National Institutes of Health COVID-19 treatment guidelines recommend against the use of antibiotic therapy for confirmed or suspected COVID-19 in the absence of another indication.[6] High illness acuity and longer lengths of stay in hospitalized patients can lead to the development of healthcare-associated infections and the spread of antibiotic-resistant pathogens.[7,8] The COVID-19 pandemic has underscored the importance of infection prevention and control as well as antibiotic stewardship to protect patients.

3. Resilience of antibiotic stewardship programs is critical for optimizing patient safety and outcomes.

CDC's Core Elements of Antibiotic Stewardship outlines structural and procedural components for antibiotic stewardship programs in outpatient, nursing home, and hospital settings. The Core Elements can be adapted to optimize treatment of respiratory infections, including COVID-19. Antibiotic stewardship programs' expertise, skills, and structure were critical for health systems' COVID-19 response, including diagnostic testing, treatment, and vaccination. With unprecedented challenges across all healthcare settings, supporting the resilience of antibiotic stewardship programs will optimize patient safety and outcomes.[9]

4. Tracking and reporting antibiotic use can identify opportunities to improve prescribing practices.

Antibiotics are critical tools for treating infections, including those that can lead to sepsis. However, any time antibiotics are used, they can cause adverse events and contribute to the development of antibiotic-resistant infections. During the COVID-19 pandemic, investigators documented an increase in the use of azithromycin, which may increase the risk for adverse drug events without providing the benefit of treatment. Tracking and reporting of antibiotic use, such as through CDC's National Healthcare Safety Network Antimicrobial Use and Resistance (AUR) Options, is key to identifying prescribing trends and opportunities to improve prescribing practices across healthcare settings.

5. There are opportunities to optimize antibiotic use during the COVID-19 pandemic and beyond.

Review the National Institutes of Health COVID-19 treatment guidelines, which recommend against the use of antibiotic therapy (including azithromycin) for people with confirmed or suspected COVID-19 in the absence of another indication.[1]

Remind patients that antibiotics do not treat viral infections such as COVID-19, and discuss possible harms of antibiotic use such as allergic reactions, Clostridioides difficile infection, and antibiotic-resistant infections. CDC's Be Antibiotics Aware patient educational materials can help patients understand when antibiotics are and aren't needed.

For hospitalized and nursing home patients, reassess antibiotic therapy when diagnostic testing results and the clinical picture do not support a bacterial co-infection or sepsis.

Assess patients' vaccination status and recommend routine and indication-specific vaccines based on guidance from the Advisory Committee on Immunization Practices (ACIP), including COVID-19 vaccination.

Participate in antibiotic stewardship activities in collaboration with your health system, state and local health department, or regional collaborative. CDC provides Training on Antibiotic Stewardship that offers 10 hours of free Continuing Education credits.*

*Fulfills Improvement Activities (IA) Patient Safety and Practice Assessment (PSPA)_23 and PSPA_24 under the Centers for Medicare & Medicaid Services (CMS) Merit-Based Incentive Programs, or MIPS.