Outpatient Antibiotic Prescriptions in France: Patients and Providers Characteristics and Impact of the COVID-19 Pandemic

Trends and geographical variations in outpatient antimicrobial consumption in Ireland in relation to socio-economic deprivation

Background

Different factors have been associated with changes in antimicrobial consumption rates in Ireland, however the relationship between socio-economic deprivation and antimicrobial consumption has not been explored. The presented ecological analysis explores the temporal and geographical variation in outpatient antimicrobial consumption and socio-economic deprivation in Ireland from January 2015 to March 2022.

Method

Deprivation index (DI) was used as a socio-economic proxy. A multilevel mixed model was applied to explore temporal variation and analyse the longitudinal antimicrobial consumption (DID) in relation to DI. Furthermore, maps were generated based on antimicrobial consumption rates, and spatial autocorrelation analyses were carried out to study geographical variation in antimicrobial consumption rates.

Results

The antimicrobial consumption rates per month varied from 26.2 DID (January 2015) to 22.1 DID (March 2022) showing an overall reduction of 16 %. Overall, total antimicrobial consumption in the multilevel model showed a consistent correlation with higher DI score (6.6 (95%CI 3.9 to 9.3)), and winter season (3.6 (95%CI 3.2 to 3.9)). In contrast, before COVID-19 showed significant lower antimicrobial consumption rates compared to during COVID-19 (-4.0 (95%CI -4.7 to -3.23)). No consistent trends were observed for geographical variation between areas.

Conclusion

Antimicrobial consumption rates decreased from 2015 to 2021 in Ireland. No geographical patterns were observed in antimicrobial consumption rates but associations between deprivation and antimicrobial consumption rates were observed.

Prescriber-level surveillance of outpatient antimicrobial consumption to enable targeted antimicrobial stewardship: a nationwide observational study, Switzerland, 2015 to 2022

BackgroundIn Europe and other high-income countries, antibiotics are mainly prescribed in the outpatient setting, which consists of primary, specialist and hospital-affiliated outpatient care. Established surveillance platforms report antimicrobial consumption (AMC) on aggregated levels and the contribution of the different prescriber groups is unknown.AimTo determine the contribution of different prescribers to the overall outpatient AMC in Switzerland.MethodsWe conducted a retrospective observational study using claims data from one large Swiss health insurance company, covering the period from 2015 to 2022. We analysed antibiotic prescriptions (ATC code J01) prescribed in the Swiss outpatient setting. Results were reported as defined daily doses per 1,000 inhabitants per day (DID) and weighted according to the total population of Switzerland based on census data.ResultsWe analysed 3,663,590 antibiotic prescriptions from 49 prescriber groups. Overall, AMC ranged from 9.12 DID (2015) to 7.99 DID (2022). General internal medicine (40.1% of all prescribed DID in 2022), hospital-affiliated outpatient care (20.6%), group practices (17.3%), paediatrics (5.4%) and gynaecology (3.7%) were the largest prescriber groups. Primary care accounted for two-thirds of the prescribed DID. Quantity and type of antibiotics prescribed varied between the prescriber groups. Broad-spectrum penicillins, tetracyclines and macrolides were the most prescribed antibiotic classes.ConclusionPrimary care contributed considerably less to AMC than anticipated, and hospital-affiliated outpatient care emerged as an important prescriber. Surveillance at the prescriber level enables the identification of prescribing patterns within all prescriber groups, offering unprecedented visibility and allowing a more targeted antibiotic stewardship according to prescriber groups.

Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data

BACKGROUND

Inappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs.

METHODS

This was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions.

RESULTS

The odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points.

CONCLUSIONS

Encouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.

Community antibiotic prescribing in patients with COVID-19 across three pandemic waves: a population-based study in Scotland, UK

OBJECTIVES

This study aims to examine community antibiotic prescribing across a complete geographical area for people with a positive COVID-19 test across three pandemic waves, and to examine health and demographic factors associated with antibiotic prescribing.

DESIGN

A population-based study using administrative data.

SETTING

A complete geographical region within Scotland, UK.

PARTICIPANTS

Residents of two National Health Service Scotland health boards with SARS-CoV-2 virus test results from 1 February 2020 to 31 March 2022 (n=184 954). Individuals with a positive test result (n=16 025) had data linked to prescription and hospital admission data ±28 days of the test, general practice data for high-risk comorbidities and demographic data.

OUTCOME MEASURES

The associations between patient factors and the odds of antibiotic prescription in COVID-19 episodes across three pandemic waves from multivariate binary logistic regression.

RESULTS

Data included 768 206 tests for 184 954 individuals, identifying 16 240 COVID-19 episodes involving 16 025 individuals. There were 3263 antibiotic prescriptions ±28 days for 2395 episodes. 35.6% of episodes had a prescription only before the test date, 52.3% of episodes after and 12.1% before and after. Antibiotic prescribing reduced over time: 20.4% of episodes in wave 1, 17.7% in wave 2 and 12.0% in wave 3. In multivariate logistic regression, being female (OR 1.31, 95% CI 1.19 to 1.45), older (OR 3.02, 95% CI 2.50 to 3.68 75+ vs <25 years), having a high-risk comorbidity (OR 1.45, 95% CI 1.31 to 1.61), a hospital admission ±28 days of an episode (OR 1.58, 95% CI 1.42 to 1.77) and health board region (OR 1.14, 95% CI 1.03 to 1.25, board B vs A) increased the odds of receiving an antibiotic.

CONCLUSION

Community antibiotic prescriptions in COVID-19 episodes were uncommon in this population and likelihood was associated with patient factors. The reduction over pandemic waves may represent increased knowledge regarding COVID-19 treatment and/or evolving symptomatology.

Diagnosis-linked antibiotic prescribing quality indicators: demonstrating feasibility using practice-based routine primary care data, reliability, validity and their potential in antimicrobial stewardship

BACKGROUND

Quality indicators (QIs) can be used to obtain valuable insights into prescribing quality. Five quantitative and nine diagnosis-linked QIs, aiming to provide general practitioners (GP) with feedback on their antibiotic prescribing quantity and quality, were previously developed and evaluated in a controlled study.

OBJECTIVE

To confirm, in a larger non-controlled study, the feasibility of using routinely collected and extracted electronic patient records to calculate the diagnosis-linked QI outcomes for antibiotic prescribing, and their reliability and validity.

METHODS

Retrospective study involving 299 Dutch general practices using routine care data (2018-2020). QIs describe total antibiotic and subgroup prescribing, prescribing percentages and first-choice prescribing for several clinical diagnoses. Practice variation in QI outcomes, inter-QI outcome correlations and sensitivity of QI outcomes to pandemic-induced change were determined.

RESULTS

QI outcomes were successfully obtained for 278/299 practices. With respect to reliability, outcomes for 2018 and 2019 were comparable, between-practice variation in outcomes was similar to the controlled pilot, and inter-QI outcome correlations were as expected, for example: high prescribing of second choice antibiotics with low first-choice prescribing for clinical diagnoses. Validity was confirmed by their sensitivity to pandemic-induced change: total antibiotic prescribing decreased from 282 prescriptions/1000 registered patients in 2018 to 216 in 2020, with a decrease in prescribing percentages for upper and lower respiratory infections, from 26% to 18.5%, and from 28% to 16%.

CONCLUSIONS

This study confirmed the fit-for-purpose (feasibility, reliability and validity) of the antibiotic prescribing QIs (including clinical diagnosis-linked ones) using routinely registered primary health care data as a source. This feedback can therefore be used in antibiotic stewardship programmes to improve GPs' prescribing routines.

Clinical and Economic Burden of Antibiotic Use Among Pediatric Patients With Varicella Infection in the Outpatient Setting: A Retrospective Cohort Analysis of Real-world Data in France

BACKGROUND

Varicella infects 90% of children before age 9. Though varicella is self-limiting, its complications may require antibiotics, though how antibiotics are utilized for varicella in France is not well known. This study assessed antibiotic use and costs associated with varicella and its complications in pediatric patients managed in the outpatient setting in France.

METHODS

A retrospective cohort study using the Cegedim Strategic Data-Longitudinal Patient Database, an electronic medical record database from general practitioners and office-based specialists in France, was conducted. Children <18 years old diagnosed with varicella between January 2014 and December 2018 with 3-month follow-up available were included. We used descriptive analysis to assess varicella-related complications, medication use, healthcare resource utilization and costs.

RESULTS

Overall, 48,027 patients were diagnosed with varicella; 15.3% (n = 7369) had ≥1 varicella-related complication. Antibiotics were prescribed in up to 25.1% (n = 12,045/48,027) of cases with greater use in patients with complications (68.1%, n = 5018/7369) compared with those without (17.3%, n = 7027/40,658). Mean medication and outpatient varicella-related costs were €32.82 per patient with medications costing a mean of €5.84 per patient; antibiotics contributed ~23% to total costs annually.

CONCLUSION

This study showed high antibiotic use for the management of varicella and its complications. A universal varicella vaccination program could be considered to alleviate complications and associated costs in France.

Identifying General Practitioners' Antibiotic Prescribing Profiles Based on National Health Reimbursement Data

Background

Antibiotic selection pressure in human medicine is a significant driver of antibiotic resistance in humans. The primary aspect of antibiotic consumption is associated with general practitioner (GP) prescriptions. We aimed to identify prescriber profiles for targeted antimicrobial stewardship programs using novel indicators.

Methods

A cross-sectional study was conducted in 2018 investigating GPs' antibiotic prescriptions in a French department, utilizing the reimbursement database of the national health service. Three antibiotic prescribing indicators were used. Specific targets were established for each indicator to identify the antibiotic prescribers most likely contributing to the emergence of resistance.

Results

Over 2018, we had 2,908,977 visits to 784 GPs, leading to 431,549 antibiotic prescriptions. Variations between GPs were shown by the 3 indicators. The median antibiotic prescription rate per visit was 13.6% (interquartile range [IQR], 9.8%-17.7%). Median ratios of the prescriptions of low-impact antibiotics to the prescriptions of high-impact antibiotics and of amoxicillin prescriptions to amoxicillin-clavulanic acid prescriptions were 2.5 (IQR, 1.7-3.7) and 2.94 (IQR, 1.7-5), respectively. We found 163 (21%) high prescribers of antibiotics with 3 distinct patterns: The first group overuses broad-spectrum antibiotics but without an overprescription rate per visit, the second group displays an overprescription rate but no excessive use of broad-spectrum antibiotics, and the third group shows both an overprescription rate and excessive use of broad-spectrum antibiotics.

Conclusions

Prescription-based indicators enable the identification of distinct profiles of antibiotic prescribers. This identification may allow for targeted implementation of stewardship programs focused on the specific prescribing patterns of each profile.

Long-term impact of COVID-19 pandemic on antibiotic use in primary care: lessons to optimize antimicrobial use

BACKGROUND

Lockdowns due to the COVID-19 pandemic was associated with changes in the pattern of use of antimicrobials, but persistence of changes after lockdowns has not been described. The objective was to describe the number of patients with dispensed antibiotic treatment and consumption of antibiotics in outpatients from primary care in Catalonia 18 months after the end of the emergency period.

RESEARCH DESIGN AND METHODS

Data for the COVID-19 pandemic period was obtained from March 2020 to December 2021. Four high transmission rate (Rt > 100) periods were established. To compare data, a simple Bayesian structural time series model was used.

RESULTS

The observed number of patients with dispensed antibiotics decreased respect to the estimated, especially during the four high transmission rate periods: April-May 2020 (lockdown period) (-42.57% and -42.68%); December 2020-February 2021 (-41.65%, -49.97% and -43.64%); October 2021 (-16.23%), and December 2021 (-20.16%). Overall antibiotic consumption was reduced by 23.37% (p = 0.002). These differences were mainly observed in those ≤ 15 years.

CONCLUSIONS

We describe the reduction in the number of patients with dispensed antibiotics and antibiotic consumption after the COVID-19 lockdown persisted in a period of recovery of healthcare accessibility. This information may help to improve antimicrobial use at the primary care level.

Exploring factors shaping antibiotic resistance patterns in Streptococcus pneumoniae during the 2020 COVID-19 pandemic

Non-pharmaceutical interventions implemented to block SARS-CoV-2 transmission in early 2020 led to global reductions in the incidence of invasive pneumococcal disease (IPD). By contrast, most European countries reported an increase in antibiotic resistance among invasive Streptococcus pneumoniae isolates from 2019 to 2020, while an increasing number of studies reported stable pneumococcal carriage prevalence over the same period. To disentangle the impacts of the COVID-19 pandemic on pneumococcal epidemiology in the community setting, we propose a mathematical model formalizing simultaneous transmission of SARS-CoV-2 and antibiotic-sensitive and -resistant strains of S. pneumoniae. To test hypotheses underlying these trends five mechanisms were built into the model and examined: (1) a population-wide reduction of antibiotic prescriptions in the community, (2) lockdown effect on pneumococcal transmission, (3) a reduced risk of developing an IPD due to the absence of common respiratory viruses, (4) community azithromycin use in COVID-19 infected individuals, (5) and a longer carriage duration of antibiotic-resistant pneumococcal strains. Among 31 possible pandemic scenarios involving mechanisms individually or in combination, model simulations surprisingly identified only two scenarios that reproduced the reported trends in the general population. They included factors (1), (3), and (4). These scenarios replicated a nearly 50% reduction in annual IPD, and an increase in antibiotic resistance from 20% to 22%, all while maintaining a relatively stable pneumococcal carriage. Exploring further, higher SARS-CoV-2 R0 values and synergistic within-host virus-bacteria interaction mechanisms could have additionally contributed to the observed antibiotic resistance increase. Our work demonstrates the utility of the mathematical modeling approach in unraveling the complex effects of the COVID-19 pandemic responses on AMR dynamics.

Wild fish from a highly urbanized river (Orge, France) as vectors of culturable Enterobacterales resistant to antibiotics

This study shows how wild fishes from urbanized rivers could be involved in the spread of antibiotic-resistant Enterobacterales. Antibiotic resistance profiles and molecular detection of clinical integron (IntI1) were carried out on 105 Enterobacterales isolated from 89 wildfish (skin or gut) belonging to 8 species. The proportion of isolates resistant to at least one antibiotic was independent of fish species and reached 28.3% within the Escherichia coli (E. coli) population and 84.7% in the non-E.coli Enterobacterales. Bacteria involved in nosocomial infections were isolated, such as E. coli, Klebsiella, and Enterobacter, as well as the environmental bacteria (Lelliottia, Butiauxella, and Kluyvera).

Antibiotic prescription in ambulatory care for COVID-19 patients: a cohort analysis in four European countries

OBJECTIVE

To analyse antibiotic prescription rates in ambulatory care for COVID-19 patients by general practitioners (GPs) in four European countries.

METHODS

A total of 4,513,955 anonymised electronic prescribing records of 3656 GPs in four European countries were analysed. Diagnosis and prescriptions were retrieved. Antibiotic prescription rates during COVID-19 consultations were analysed and compared between France, the UK, Belgium and Romania.

RESULTS

Overall prescription rate was in France and Belgium (6.66 and 7.46%). However, analysing median GP prescribing rates, we found that 33.9% of the GPs in Belgium prescribed antibiotics with a median of 16 prescriptions per 100 COVID-19 consultations, while 55.21% of the GPs in France prescribed a median of 8 antibiotic prescriptions per 100 COVID-19 consultations. Overall antibiotic prescription rates were less in Romania than in the UK (22% vs 32%); however, 73% of the Romanian GPs vs 57% of the British GPs prescribed antibiotics. Depending on the country, the proportion of each type of antibiotic was statistically different, with the proportion of azithromycin being more than 50% of all antibiotics in each country except for the UK where it was less than 1%.

CONCLUSION

Both individual GPs prescribing patterns in addition to overall consumption patterns should be analysed in order to implement a tailored antimicrobial stewardship programme. Furthermore, antibiotic prescribing rates in COVID-19 are lower than other respiratory tract infections.

Outpatient antibiotic prescribing during the first two years of the COVID-19 pandemic: A nationwide register-based time series analysis

The COVID-19 pandemic has imposed an enormous burden on health care systems around the world. Simultaneously, many countries have reported a decrease in the incidence of other infectious diseases, such as acute respiratory infections, leading to a decline in outpatient antibiotic use. The aim of this study is to assess the impact of the COVID-19 pandemic on outpatient antibiotic prescribing in Finland during the first 2 years of the pandemic. We used nationwide register data, applied descriptive methods, and conducted an interrupted time series analysis (ITSA) using ARIMA modelling. Results from the ARIMA modelling showed that at the baseline, before the pandemic, the level of monthly number of antibiotic prescriptions was 248,560 (95% CI: 224,261 to 272,856; p<0.001) and there was a decreasing trend of 1,202 in monthly number of prescriptions (95% CI: -2,107 to -262; p<0.01). After the COVID-19 pandemic began, there was a statistically significant decline of 48,470 (95% CI: -76,404 to -20,535, p<0.001) prescriptions (-19.5% from the baseline level). The greatest decrease in antibiotic prescribing was observed among children aged 0-17 years. While antibiotic prescribing declined in all antibiotic groups associated with respiratory tract infections, the decrease from 2019 to 2020 was the largest with azithromycin (52.6%), amoxicillin (44.8%), and doxycycline (43.8%). Future studies should continue exploring antibiotic prescribing trends during the COVID-19 pandemic and beyond.

Knowledge of recommended antibiotic treatments for community-acquired infections in general medical practice: a cross-sectional study in Occitanie region, France

To assess and analyse the knowledge of recommended antibiotic treatments, focusing on the appropriate drugs and treatment durations for the most common community-acquired infections in general medical practice in Occitanie region, France. A web-based survey was conducted over a 3-month period, from October, 2018 to January, 2019. All participants answered directly through the online platform. For the analysis of overtreatment risk, a score based system was adopted and two scores were produced: the duration score and the treatment score. 413 general practitioners completed the survey. The overall rate of concordance with guidelines in terms of both drug choice and treatment length was 2974/4956 (60%) answers. Diseases with at least 70% good answers included cystitis, group A streptococcal pharyngitis, and bacterial superficial skin infections. Diseases with fewer than 50% good answers included pyelonephritis, dog bite wounds, and community-acquired pneumonia in patients aged ≥ 65 years. Factors associated with the risk of overtreatment were age > 40 years, country setting and hospital employment. Knowledge of treatment durations is satisfactory with 60% of recommendations being met. However, varying levels were observed according to different diseases. This study highlighted a very high rate of adherence when recommendations were clear. In contrast, low levels of adherence were observed when recommendations were ambiguous or when conflicting guidelines existed.

The impact of COVID-19 national restrictions on dental antibiotic dispensing trends and treatment activity in England: January 2016 to July 2021

Introduction

Reducing inappropriate antibiotic prescribing tempers the growing threat of antimicrobial resistance. We aimed to quantify the associated impact of COVID-19-related national restrictions in England on dental antibiotic dispensing and describe changes in appointments and modes of delivery of care.

Methods

Interrupted time series analyses were completed using NHS Business Service Authority (NHSBSA) ePACT2 data to measure the associated change in antibiotic dispensing in England following COVID-19-related restrictions (which began March 2020). For face-to-face dental consultations, NHS dental treatment plan (FP17) data were used. For remote consultations during the COVID-19 period, NHSBSA Compass system remote management data were used.

Results

Between January 2016 and February 2020, there was a decreasing trend in antibiotic dispensing (-0.02 per 1000 population per month, P < 0.05). In contrast, there was an increase of 0.98 per 1000 population (P < 0.05) in March. The peak in antibiotic use occurred between June 2020 and July 2020, once the restrictions were eased. At the end of the study period (July 2021), the elevated prescribing trend had not returned to pre-pandemic counterfactual levels, although exhibiting a declining trend. A stable trend in dental treatment plans was seen pre-COVID-19, with a sharp decline coinciding with the restrictions. Dental treatment plans had not yet returned to the higher pre-pandemic levels.

Conclusions

Dental antibiotic prescribing significantly increased with the national COVID-19 restrictions when service delivery was altered with the closure of dental practices and introduction of remote consultations. Teledentistry was likely associated with inappropriate antibiotic prescribing. Continued antimicrobial stewardship and prudent use of antibiotics in dentistry is important.

Impact of the COVID-19 Pandemic on Community Consumption of Antibiotics for Systemic Use and Resistance of Invasive Streptococcus pneumoniae in Slovenia

The present study aims to investigate the impact of the COVID-19 pandemic on community antibiotic consumption and the resistance of invasive Streptococcus pneumoniae (2015-2022) to penicillin in Slovenia. During the pandemic in 2020 and 2021, the total use of antibiotics for systemic use decreased by 23.5% and 24.3%, expressed in defined daily doses per 1000 inhabitants per day (DID), while the use of penicillins, macrolides and broad-spectrum penicillins decreased by 30%, 20% and by 17.5%, respectively, and that of broad-spectrum macrolides fell by 17.1%. The incidence of invasive pneumococcal diseases (IPD) in Slovenia had a large decline during the pandemic. Decreased resistance to macrolides was significantly associated with decreased use of macrolides, while for penicillins the correlation could not be statistically confirmed. The proportion of PCV13 serotypes in IPD in Slovenia decreased after the introduction of the vaccine in the national programme, falling from 81.6% in 2015 to 45.5% in 2022. We noticed a decrease in the serotypes 1, 14, 9V, 7F, 4, 6A and an increase in the serotypes 3, 8, 22F, 11A, 23A and 15A. National interventions during the COVID-19 pandemic substantially decreased outpatients' antibiotic consumption, as well as incidence and resistance of invasive S. pneumoniae.

Trends in Pseudomonas aeruginosa (P. aeruginosa) Bacteremia during the COVID-19 Pandemic: A Systematic Review

Pseudomonas aeruginosa (P. aeruginosa) is among the most common pathogens associated with healthcare-acquired infections, and is often antibiotic resistant, causing significant morbidity and mortality in cases of P. aeruginosa bacteremia. It remains unclear how the incidence of P. aeruginosa bacteremia changed during the Coronavirus Disease 2019 (COVID-19) pandemic, with studies showing almost contradictory conclusions despite enhanced infection control practices during the pandemic. This systematic review sought to examine published reports with incidence rates for P. aeruginosa bacteremia during (defined as from March 2020 onwards) and prior to the COVID-19 pandemic. A systematic literature search was conducted in accordance with PRISMA guidelines and performed in Cochrane, Embase, and Medline with combinations of the key words (pseudomonas aeruginosa OR PAE) AND (incidence OR surveillance), from database inception until 1 December 2022. Based on the pre-defined inclusion criteria, a total of eight studies were eligible for review. Prior to the pandemic, the prevalence of P. aeruginosa was on an uptrend. Several international reports found a slight increase in the incidence of P. aeruginosa bacteremia during the COVID-19 pandemic. These findings collectively highlight the continued importance of good infection prevention and control and antimicrobial stewardship during both pandemic and non-pandemic periods. It is important to implement effective infection prevention and control measures, including ensuring hand hygiene, stepping up environmental cleaning and disinfection efforts, and developing timely guidelines on the appropriate prescription of antibiotics.

Antibiotic Utilization during COVID-19: Are We Over-Prescribing?

The aims of this study were to analyze the utilization of antibiotics before (2018, 2019) and during the COVID-19 pandemic (2020) and the practice of prescribing antibiotics in outpatient settings for COVID-19 patients during the 2020-2022 period. The Anatomical Therapeutic Chemical Classification/Defined Daily Dose methodology was used for the analysis of outpatient antibiotic utilization in the Republic of Srpska. The data was expressed in DDD/1000 inhabitants/day. The rate of antibiotics prescribed to COVID-19 outpatients was analyzed using medical record data from 16,565 patients registered with B34.2, U07.1, and U07.2 World Health Organization International Classification of Diseases 10th revision codes. During 2020, outpatient antibiotic utilization increased by 53.80% compared to 2019. At least one antibiotic was prescribed for 91.04%, 83.05%, and 73.52% of COVID-19 outpatients during 2020, 2021, and the first half of 2022, respectively. On a monthly basis, at least one antibiotic was prescribed for more than 55% of COVID-19 outpatients. The three most commonly prescribed antibiotics were azithromycin, amoxicillin/clavulanic acid, and doxycycline. The trend of repurposing antibiotics for COVID-19 and other diseases treatment might be a double-edged sword. The long-term effect of this practice might be an increase in antimicrobial resistance and a loss of antibiotic effectiveness.

Changes in Medication Prescribing Due to COVID-19 in Dental Practice in Croatia-National Study

The 2019 coronavirus pandemic (COVID-19) has affected clinical practice and, consequently, drug prescribing in dental practice. We investigated how the pandemic affected the prescribing behavior of dentists in Croatia. Data on prescribing practices for this study were provided by the Croatian Health Insurance Institute. The analysis included the number of prescriptions, costs, and the number of packages prescribed. The World Health Organization's defined daily dose per 1000 inhabitants (DID) per day was used as an objective utilization comparison. During the first pandemic year, prescribing practice changed the most. Wide-spectrum antibiotics, analgesics, and antiseptics showed the highest trend in change. A statistically significant change in prescribing practices during the pandemic period was noted for amoxicillin with clavulanic acid, ibuprofen, and ketoprofen which showed an increase in trend, while cephalexin and diclofenac showed a statistically significant decrease. The highest increase in trend was recorded for azithromycin, at +39.3%. The COVID-19 pandemic has been associated with a marked increase in medication utilization, especially in the first year of the pandemic. The increase in wide-spectrum antibiotic classes needs to be addressed and regulated so that patients accept that antibiotics are not a substitute for dental treatment and dentists always start treatment with narrow-spectrum antibiotics regardless of specific times, as is the case with the pandemic.

Understanding the impact of COVID-19 on dental antibiotic prescribing across England: 'it was a minefield'

Introduction The COVID-19 pandemic impacted significantly on dental service delivery across England.

Objective To explore how and why the pandemic affected antibiotic prescribing by primary care dentists.

Methods Mixed-methods study: secondary analysis of routinely collected NHS dental antibiotic prescribing data from before and during the pandemic; and an online survey of dentists (NHS and private) across England's regions.

Results Dental antibiotic prescribing increased 22% in the pandemic's first year, with regional variation from a 12.1% increase in London to 29.1% in East of England. Of 159 dentists surveyed, 60% had prescribed 'many more' antibiotics. Some urgent dental centres required antibiotics before accepting referrals, irrespective of clinical appropriateness. Diagnosing remotely was hard. Antibiotics were used to delay aerosol generating procedures and fill gaps in services. Widespread frustration existed.

Discussion Maintaining access to urgent dental care during a future pandemic would include availability of high-grade personal protective equipment for dental teams. Everyone must understand the impact of restricted dental access on antibiotic overprescribing and hence antibiotic resistance.

Conclusion Reduced dental access and changes in dental service delivery because of the pandemic increased antibiotic prescribing. Ensuring uninterrupted access for all to effective urgent dental care is an important element of global efforts to tackle antibiotic resistance.

Remote management of patients during the COVID-19 pandemic resulted in increased antibiotic prescribing in each of England's regions. Most dentists were not confident managing patients with acute dental conditions remotely. Ensuring access to face-to-face dentistry is an important part of efforts to tackle antibiotic resistance.

Dentists felt frustrated about being prevented from providing the dental procedures needed to provide safe and effective care to people in pain. Many also expressed concern about the impact of increased antibiotic prescribing on antibiotic resistance and their experience of increased patient expectation that antibiotics are appropriate for toothache.

Preparedness plans for future pandemics should recognise that antibiotics are not a substitute for dental procedures and dentistry was the only part of the NHS to experience an increase in antibiotic prescribing during the COVID-19 pandemic. Planners should aim to ensure sufficient face-to-face urgent dental care provision immediately upon implementation of pandemic restrictions.

Consumption of Antibiotics in Primary Care Setting before and during COVID-19 Pandemic in Republic of Srpska, Bosnia and Herzegovina

The pandemic of COVID-19 has brought many changes in health care systems at all levels of health care. The increase in the number of cases of COVID-19 has led to overuse and misuse of antibiotics.The aim of this study was to compare the consumption of antibiotics for systemic use in outpatients in the Republic of Srpska (RS), before and during the first year of the COVID-19 pandemic, as well as the association between antibiotic consumption and the rate of incidence and mortality of COVID-19. The total consumption of the antibiotics for systemic use (J01) in outpatients in the Republic of Srpska during 2019 was 19.40 DDD/TID, with an increase to 30.80 DDD/TID in 2020.Significantly higher use of penicillin (10.58 ± 11.01 DDD/TID in 2019 vs. 17.10 ± 13.63 DDD/TID in 2020), cephalosporins (2.68 ± 1.90 DDD/TID in 2019 vs. 5.93 ± 2.77 DDD/TID in 2020) and macrolides (2.14 ± 2.22 DDD/TID in 2019 vs. 3.40 ± 3.44 DDD/TID in 2020) was observed during the pandemic period. It is necessary to improve the prescribing practice of antibiotics at the primary health care level, public awareness about rational use of antibiotics, as well as the current antibiotic stewardship programs and control their implementation.

Long-Term Impact of the COVID-19 Pandemic on In-Hospital Antibiotic Consumption and Antibiotic Resistance: A Time Series Analysis (2015-2021)

The coronavirus disease 2019 (COVID-19)-pandemic-related overload of health systems has compromised the application of antimicrobial stewardship (AS) models and infection prevention and control (IPC) programs. We aimed to evaluate the impact of COVID-19 on antimicrobial consumption (AC) and antimicrobial resistance (AMR) in the University Hospital of Modena. A time series analysis with an autoregressive integrated moving average model was conducted from January 2015 to October 2021 to evaluate the AC in the whole hospital and the intensive care unit (ICU), the incidence density (ID) of bloodstream infections (BSIs) due to the main multidrug-resistant organisms, and of C. difficile infections (CDIs). After an initial peak during the COVID-19 period, a decrease in the trend of AC was observed, both at the hospital (CT: -1.104, p = 0.025) and ICU levels (CT: -4.47, p = 0.047), with no significant difference in the single classes. Among the Gram-negative isolates, we observed a significant increase only in the level of BSIs due to carbapenem-susceptible Pseudomonas aeruginosa (CL: 1.477, 95% CI 0.130 to 2.824, p = 0.032). Considering Gram-positive bacteria, an increase in the level of BSIs due to methicillin-resistant Staphylococcus aureus and in the trend of CDIs were observed, though they did not reach statistical significance (CL: 0.72, 95% CI -0.039 to 1.48, p = 0.062; CT: 1.43, 95% CI -0.002 to 2.863, p = 0.051; respectively). Our findings demonstrated that the increases in AMR and AC that appeared in the first COVID-19 wave may be later controlled by restoring IPC and AS programs to pre-epidemic levels. A coordinated healthcare effort is necessary to address the longer-term impact of COVID-19 on AC to avoid irreversible consequences on AMR.

Antibiotics Use in Primary Care during COVID-19

During national health emergencies such as the COVID-19 pandemic, a robust primary care system plays a crucial role in triaging, educating patients and testing [...]