Outpatient COVID-19 Visits and Antibiotics: Did We Overprescribe?

In the wake of the COVID-19 pandemic our attention has been wholly focused on the fire right in front of us. And rightfully so…but we’ve seen this before and what tends to happen is that other health issues fall forgotten, only to become inflamed.

During the Ebola crisis in 2014-2016, there were significant cases and challenges responding to endemic diseases such as tuberculosis, malaria, and HIV/AIDS. In the case of COVID-19, it will likely take years to truly understand the impact of the pandemic on other infectious diseases. One question though that has increasingly come up since the early days of COVID-19, was the use of antibiotics.

During the first year, it seemed as if antibiotics were given to patients suffering the severe effects of COVID-19 at an alarming rate. Many were hospitalized for significant periods of time and at risk for coinfections, and often everything but the kitchen sink was thrown at treating them. As we start to step back and look at the bigger picture and implications of this pandemic, antibiotic prescriptions and potential resistance will increasingly be a discussion.

In a recent publication within JAMA, a research team sought to assess antibiotic prescriptions associated with COVID-19 outpatient visits in medicare beneficiary patients between April 2020 and April 2021. Over the course of a year, did our prescribing habits change? Assessing Medicare 100% carrier claims and Part D event files with outpatient visits, they limited visits with the primary diagnosis of COVID-19 (U0.7.1) and then excluded those visits in which antibiotics would be always or usually appropriate based on clinical guidance. Visits were also linked if an antibiotic was prescribed within 7 days before or after the visit.

After their assessment, the authors reported that of the 1,169,120 outpatient visits fitting this requirement, 346,204 (39.6%) had antibiotics prescribed. They noted that “prescribing was highest in the ED (33.9%), followed by telehealth (28.4%), urgent care (25.8%), and office (23.9%) visits. Azithromycin was the most frequently prescribed antibiotic (50.7%), followed by doxycycline (13.0%), amoxicillin (9.4%), and levofloxacin (6.7%). Urgent care had the highest percentage of azithromycin prescriptions (60.1%), followed by telehealth (55.7%), office (51.5%), and ED (47.4%). Differences were observed by age, sex, and location (Table). Non-Hispanic White beneficiaries received antibiotics for COVID-19 more frequently (30.6%) than other racial and ethnic groups: American Indian/Alaska Native (24.1%), Asian/Pacific Islander (26.5%), Black or African American (23.2%), and Hispanic (28.8%).” Higher rates of antibiotic prescribing appeared to be higher in the winter, as there was 17.5% use in May 2020 but it jumped to 33.3% in October 2020.

These findings are deeply worrisome—consider that 30% of outpatient visits for COVID-19 among those Medicare beneficiaries were linked to antibiotic use during a pandemic of a novel respiratory virus. Even more so, half of those patient prescribed antibiotics were given azithromycin.

When you consider that telehealth visits had the second highest rate of prescribing, it further reinforces how important antibiotic stewardship is and a desperate need to develop more pandemic-responsive stewardship initiatives. Time will tell if resistance and often antibiotic-induced adverse events like C diff may occur.