In the wake of the COVID-19 pandemic, our attention has been completely focused on the fire right in front of us. And rightly so… but we’ve seen this before, and what usually happens is that other health problems are forgotten, just to get inflamed.
During the Ebola crisis in 2014-2016, there were significant cases and challenges that responded to endemic diseases such as tuberculosis, malaria and HIV / AIDS. In the case of COVID-19, it will probably take years to truly understand the impact of the pandemic on other infectious diseases. One issue, though increasingly emerging since the early days of COVID-19, was the use of antibiotics.
During the first year, it seemed as if antibiotics were being given to patients suffering from the severe effects of COVID-19 at an alarming rate. Many were hospitalized for extended periods and at risk of concomitant infections, and often anything other than the kitchen sink was thrown away to treat them. As we begin to step back and look at the bigger picture and the consequences of this pandemic, antibiotic prescriptions and potential resistance will increasingly be a discussion.
In a recent disclosure within JAMA, a research team sought to evaluate antibiotic prescriptions in connection with COVID-19 outpatient visits to patients receiving medication between April 2020 and April 2021. Over the course of a year, did our prescribing habits change? By assessing Medicare 100% carrier requirements and Part D event visits with outpatient visits, they limited visits with the primary diagnosis of COVID-19 (U0.7.1) and then excluded those visits where antibiotics would always or normally be appropriate based on clinical guidance. Visits were also associated if an antibiotic was prescribed within 7 days before or after the visit.
According to their assessment, the authors reported that of the 1,169,120 outpatient visits that matched this requirement, 346,204 (39.6%) had antibiotics prescribed. They noted that “prescription was highest in ED (33.9%), followed by telesealth (28.4%), emergency care (25.8%) and office visits (23.9%). Azithromycin was the most frequently prescribed antibiotic (50.7%), followed by doxycycline (13.0%), amoxicillin (9.4%) and levofloxacin (6.7%) Acute care had the highest percentage of azithromycin prescriptions (60.1%), followed by telecom health (55.7%), office (51.5%) and ED (47.4%) Differences were observed by age, sex and location (table) Non-Hispanic white recipients received antibiotics for COVID-19 more frequent (30.6%) than other racial and ethnic groups: Native Americans / Alaska (24.1%), Asia / Pacific Islanders (26.5%), Blacks, or African Americans (23.2%), and Latin American (28.8%) .Higher rates of antibiotic prescribing appeared to be higher in winter as there was 17.5% use in May 2020, but it jumped to 33.3% in October 2020.
These findings are deeply troubling – consider that 30% of COVID-19 outpatient visits among these Medicare recipients were associated with antibiotic use during a pandemic of a new respiratory virus. To an even greater extent, half of the patients who were prescribed antibiotics received azithromycin.
When one considers that telesealth visits had the second highest prescription rate, it further reinforces the importance of antibiotic management and a desperate need to develop more pandemic-responsive stewardship initiatives. Time will tell if resistance and often antibiotic-induced side effects like C diff can happen.