Health system sees nearly 80% drop in antibiotics for RTIs amid pandemic
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A “marked decrease” in respiratory virus detections correlated with a 79% reduction in ambulatory antibiotic prescribing rates for respiratory tract infections during the COVID-19 pandemic, researchers of a pre-post study wrote.
The trend was observed at University of Wisconsin (UW) Health, an academic health care system with more than 80 ambulatory sites and 7,000,000 ambulatory encounters each year, according to the researchers.
“We were seeing, on a state‐wide level, dramatic drops in respiratory viruses through the usual respiratory viral season,” Alexander J. Lepak, MD, a professor of infectious disease at the University of Wisconsin School of Medicine and Public Health, told Healio Primary Care.
A similar trend was observed in other geographic regions, he added.
“As respiratory viruses are unfortunately one of the most common reasons for antibiotic prescriptions in ambulatory care, we hypothesized that the dramatic drop in respiratory viruses would be associated with a drop in ambulatory antibiotic prescriptions,” Lepak said. “We felt this was an interesting opportunity to quantify the impact respiratory viruses have on ambulatory antibiotic prescribing.”
Lepak and colleagues searched Wisconsin’s surveillance polymerase chain reaction data for influenza, respiratory syncytial virus, human parainfluenza virus, human metapneumovirus, seasonal coronavirus, adenovirus and enterovirus/rhinovirus. They also utilized an electronic health record tool to analyze changes in respiratory virus detections, antibiotic prescriptions for every 1,000 patient encounters and antibiotic prescriptions for respiratory tract infections per 1,000 patient encounters. The data were collected from a pre-pandemic timespan (July 2018 to February 2020), a 1-month run-in timespan (March 2020) and a COVID-19 pandemic timespan (April 2020 to February).
The researchers reported in JAMA Internal Medicine that the number of ambulatory patient visits were similar during the pre- and post-pandemic period (637,000 vs. 661,000 monthly; P = 0.24). However, monthly influenza-, RSV- and seasonal coronavirus-related visits dropped during the pandemic when compared with prior seasons (12 vs. 4,800; P < .001). Other monthly respiratory virus detections also dropped (560 vs. 228; P < .001).
Although antibiotic prescribing rose during winter respiratory viral seasons in the pre-pandemic period, short-term antibiotic prescribing rates dropped during the pandemic and stayed low throughout the pandemic period, according to the researchers. After adjusting for this seasonality, monthly antibiotic prescriptions for respiratory tract infections declined for each 1,000 patient encounters (79%; 10.5 prescriptions vs. 2.2 prescriptions; P < .001). Non-influenza virus showed the strongest relationship with antibiotic prescribing for respiratory tract infections (r = 0.82; P < .001).
“This translated in our health system to approximately 10 fewer antibiotic prescriptions for respiratory tract infections per 1,000 encounters, which turns into almost 80,000 fewer prescriptions during the 12‐month COVID‐19 pandemic period in our study,” Lepak said in the interview.
“We expected a drop, but I will admit I didn’t expect this dramatic of a drop,” he continued. “That number still gives me pause and was surprising to see how big of an impact it was.”
According to Lepak, strategies to limit the spread of COVID‐19 likely had a “dramatic effect” on lowering respiratory virus activity and provided a “huge opportunity” to significantly reduce antibiotic prescribing rates for respiratory viruses.
He added that the findings underscore the need for “more comprehensive respiratory viral testing that is accessible and timely” in ambulatory care settings.
“When providers and patients know what they have, and can confirm it is a respiratory virus, it may be far more likely that both provider and patient are more comfortable with symptomatic therapy only and avoiding antibiotic prescriptions,” he said.
Perspective
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Although this interesting paper by Lepak and colleagues has the usual limitations of EHR-based studies, its findings seem representative of the patterns that have been observed in clinical practices and epidemiologic studies during the past year.
The Lepak study also goes further and examines patterns in antibiotic prescriptions within the same health system, finding a significant decrease in prescriptions for respiratory tract illnesses but not for other causes. This novel finding also makes sense in terms of what we see in clinical practice. Although the study’s design did not include individual patient outcomes (eg, if a patient who was not initially prescribed antibiotics for respiratory tract infection required them later), the overall finding of a 79% decrease in antibiotic prescriptions for respiratory tract infections in non-hospitalized patients is quite impressive.
This study highlights two longstanding public health issues: No.1, the seasonal burden of respiratory tract infections, and No. 2, the problem of antibiotic overprescribing for non-bacterial infections in the context of the COVID-19 pandemic. Masking and other non-pharmacologic interventions for respiratory tract infections are highly effective when used consistently. The experience of the past year should encourage us to keep those tools available and socially acceptable during “cold and flu season” in order to reduce the annual burden of illness, days of work and school lost among the young and mortality among the older and medically vulnerable.
Prior to the COVID-19 pandemic, the CDC and WHO considered antimicrobial resistance one of the biggest public health challenges of our time, and there have been concerns about the pandemic worsening some of the trends driving antimicrobial resistance, including the frequent use of broad-spectrum antibiotics in patients with severe COVID-19 and decreased consistency of non-COVID isolation precautions due to strains on personal protective equipment supplies.
Further studies of how the pandemic has affected antimicrobial resistance, what measures are effective to mitigate this and how this differs in hospitals compared with ambulatory settings are needed. It would also be important to explore the relative role of prescriber behavior (eg, tendency to prescribe antibiotics) compared with patient preference and care-seeking behavior (eg, threshold to go see a doctor) and how office closings and telemedicine might have contributed to these. It would also be interesting to see if there were differences in respiratory tract infections and antibiotic prescription patterns between states based on what pandemic restrictions were implemented and when.
References:
CDC. Antibiotic / Antimicrobial Resistance. Available at: https://www.cdc.gov/drugresistance/index.html. Accessed June 21, 2021.
Olsen SJ, et al. MMWR Morbid Mortal Weekly Rep. 2020;doi:10.15585.mmwr.mm6937a6.
Peek K. The Scientific American. Flu has disappeared worldwide during the COVID-19 pandemic. Available at: https://www.scientificamerican.com/article/flu-has-disappeared-worldwide-during-the-covid-pandemic1. Accessed June 21, 2021.
Rodríguez-Baño J, et al. Trans R Soc Trop Med Hyg. 2021;doi:10.1093/trstmh/trab048.
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