Trends in antibiotic use in a UK secondary care prior to and during the COVID-19 pandemic: a cross-sectional retrospective study
Authors: Elshenawy R Abdelsalam , Umaru N , Aslanpour Z 
Published: November 2024

Abstract

Introduction
Antimicrobial resistance (AMR) is a rapidly escalating global health challenge. To address this, the UK Government developed a 5-year action plan, 'Confronting Antimicrobial Resistance 2024 to 2029,' aimed at optimising antimicrobial use.1 The World Health Organisation (WHO) promotes antimicrobial stewardship (AMS) and developed the AWaRe classification system to guide global AMS implementation. The defined daily dose (DDD) standardises antibiotic use comparisons.2 The COVID-19 pandemic significantly impacted health services, particularly in secondary care, potentially exacerbating AMR due to increased antibiotic use.3

Aim
To evaluate changes in antibiotic use in a UK secondary care setting following the onset of the COVID-19 pandemic in 2020 compared to 2019.

Methods
This cross-sectional retrospective study evaluated antibiotic use among adult patients admitted to an NHS Foundation Trust in England. The focus was on those prescribed antibiotics for respiratory tract infections (RTIs) and pneumonia in 2019 and 2020. Data from 640 patient records were extracted using a validated tool based on the WHO AWaRe classification, with antibiotic use measured using the Defined Daily Dose (DDD). The study included patients aged 25 and above, immunocompromised individuals, pregnant women, and those treated for RTIs. It was registered under ISRCTN number 14825813 and received ethical approval from the University of Hertfordshire Ethics and Health Research Authority (HRA). The Citizens Senate reviewed the study protocol, ensuring public and patient involvement.

Results
The results show a notable increase in the Defined Daily Dose (DDD) of several antibiotics during the COVID-19 pandemic. In the "Access" category, amoxicillin usage rose from 1.33 DDD pre-pandemic to 4.33 DDD in 2020. Co-amoxiclav remained nearly constant at around 15 DDD but showed a marked increase compared to other antibiotics. In the "Watch" category, azithromycin increased from 3 to 9 DDD, and clarithromycin from 32 to 35.5 DDD. Levofloxacin usage doubled from 13 to 26 DDD. The "Reserve" category showed no significant increase, indicating stable consumption.

Discussion and conclusion
Understanding trends in antibiotic prescribing during the COVID-19 pandemic is pivotal for effective management in secondary care settings. The significant increase in the "Watch" category of antibiotics, particularly macrolides like azithromycin and clarithromycin, highlights the need for stringent antimicrobial stewardship. This rise may reflect changes in prescribing behaviour due to the pandemic. Monitoring antibiotic use is vital to mitigate the AMR challenge. Additionally, the increased use of levofloxacin during the pandemic, despite MHRA safety alerts about its potentially severe side effects, highlights the importance of cautious antibiotic prescribing and prompt discontinuation at the first signs of adverse reactions.
The COVID-19 pandemic has significantly influenced antibiotic prescribing trends, highlighting the urgent need for sustainable antimicrobial stewardship in secondary care. This study reveals a notable increase in "Watch" category antibiotics, particularly azithromycin and clarithromycin, underscoring the need for stringent stewardship. Optimised antibiotic use is crucial for patient safety, improving treatment quality, and saving lives. The increased reliance on levofloxacin, despite known risks, emphasises the importance of careful prescribing. Prioritising responsible antibiotic use is essential to combat antimicrobial resistance, necessitating enhanced monitoring and stewardship efforts.

References
1. Department of Health and Social Care. UK 5-year action plan for antimicrobial resistance 2024 to 2029 [Internet]. GOV.UK. 2024. Available from: https://www.gov.uk/government/publications/uk-5-year-action-plan-for-antimicrobial-resistance-2024-to-2029.
2. WHO. The WHO AWaRe (Access, Watch, Reserve) antibiotic book - Infographics [Internet]. www.who.int. 2023. Available from: https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2022.02.
3. Abdelsalam Elshenawy R, Umaru N, Aslanpour Z. Impact of COVID-19 on “Start Smart, Then Focus” Antimicrobial Stewardship at One NHS Foundation Trust in England Prior to and during the Pandemic. COVID [Internet]. 2024 Jan 1;4(1):102–16. Available from: https://www.mdpi.com/2673-8112/4/1/10.