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Global antibiotic use during the COVID-19 pandemic: analysis of pharmaceutical sales data from 71 countries, 2020–2022

Arindam Nandi, Simone Pecetta, David E. Bloom

eClinicalMedicine · 2023 · CC BY

doi:10.1016/j.eclinm.2023.101848

Abstract

Background. Despite bacterial coinfection rates of less than 10%, antibiotics are prescribed to an estimated 75% of patients with COVID-19, potentially exacerbating antimicrobial resistance. We estimated the associations of COVID-19 cases and vaccinations with global antibiotic sales during the first two years of the COVID-19 pandemic.

Methods. We obtained monthly data on broad-spectrum antibiotic sales volumes (cephalosporins, penicillins, macrolides, and tetracyclines) in 71 countries during March 2020–May 2022 from the IQVIA MIDAS® database. These data were combined with country-month-level COVID-19 case and vaccination data from Our World in Data. We used least squares (pooled) and fixed-effects panel data regression models, accounting for country characteristics, to estimate the associations between antibiotic sales volumes and COVID-19 cases and vaccinations per 1000 people.

Findings. Sales of all four antibiotics fell sharply during April and May 2020, followed by a gradual rise to near pre-pandemic levels through May 2022. In fixed-effects regression models, a 10% increase in monthly COVID-19 cases was associated with 0.2%–0.3% higher sales of cephalosporins, 0.2%–0.3% higher sales of penicillins, 0.4%–0.6% higher sales of macrolides, and 0.3% higher sales of all four antibiotics combined per 1000 people. Across continents, a 10% increase in monthly COVID-19 cases was associated with 0.8%, 1.3%, and 1.5% higher macrolides sales in Europe, North America, and Africa respectively. Sales of other antibiotics across continent were also positively associated with COVID-19 cases, although the estimated associations were smaller in magnitude. No consistent associations were observed between antibiotic sales and COVID-19 vaccinations. Results from pooled regression analysis were similar to those from the fixed-effects models.

Interpretation. Antibiotic sales were positively associated with COVID-19 cases globally during 2020–2022. Our findings underline that antibiotic stewardship in the context of COVID-19 remains essential.

Funding. 10.13039/100000865Bill & Melinda Gates Foundation.

References 54

1.
Murray C.J., Ikuta K.S., Sharara F., et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399:629-655.
Not in our library10.1016/s0140-6736(21)02724-0
2.
Dadgostar P. Antimicrobial resistance: implications and costs. Infect Drug Resist. 2019;12:3903-3910.
Not in our library10.2147/idr.s234610
3.
A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance · 2014
No notice
4.
Dyar O.J., Beović B., Vlahović-Palčevski V., Verheij T., Pulcini C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti Infect Ther. 2016;14:403-413.
Not in our library10.1586/14787210.2016.1151353
5.
Sulis G., Sayood S., Gandra S. Antimicrobial resistance in low- and middle-income countries: current status and future directions. Expert Rev Anti Infect Ther. 2022;20:147-160.
Not in our library10.1080/14787210.2021.1951705
6.
Mutai W.C., Mureithi M.W., Anzala O., et al. High prevalence of multidrug-resistant clostridioides difficile following extensive use of antimicrobials in hospitalized patients in Kenya. Front Cell Infect Microbiol. 2021;10.
Not in our library10.3389/fcimb.2020.604986
7.
Lim J.M., Singh S.R., Duong M.C., Legido-Quigley H., Hsu L.Y., Tam C.C. Impact of national interventions to promote responsible antibiotic use: a systematic review. J Antimicrob Chemother. 2020;75:14-29.
Not in our library10.1093/jac/dkz348
8.
Llor C., Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014;5:229-241.
Not in our library10.1177/2042098614554919
9.
Global increase and geographic convergence in antibiotic consumption between 2000 and 2015 · 2018
No notice
10.
Klein E.Y., Milkowska-Shibata M., Tseng K.K., et al. Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000–15: an analysis of pharmaceutical sales data. Lancet Infect Dis. 2020;21(1):107-115.
Not in our library10.1016/s1473-3099(20)30332-7
11.
Langford B.J., So M., Raybardhan S., et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect. 2021;27:520-531.
Not in our library10.1016/j.cmi.2020.12.018
12.
Rose A.N., Baggs J., Wolford H., et al. Trends in antibiotic use in United States hospitals during the coronavirus disease 2019 pandemic. Open Forum Infect Dis. 2021;8:ofab236.
Not in our library10.1093/ofid/ofab236
13.
Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study · 2021
No notice
14.
Karami Z., Knoop B.T., Dofferhoff A.S.M., et al. Few bacterial co-infections but frequent empiric antibiotic use in the early phase of hospitalized patients with COVID-19: results from a multicentre retrospective cohort study in The Netherlands. Infect Dis (Lond). 2021;53:102-110.
Not in our library10.1080/23744235.2020.1839672
15.
Fukushige M., Ngo N.-H., Lukmanto D., Fukuda S., Ohneda O. Effect of the COVID-19 pandemic on antibiotic consumption: a systematic review comparing 2019 and 2020 data. Front Public Health. 2022;10.
Not in our library10.3389/fpubh.2022.946077
16.
Alshaikh F.S., Godman B., Sindi O.N., Seaton R.A., Kurdi A. Prevalence of bacterial coinfection and patterns of antibiotics prescribing in patients with COVID-19: a systematic review and meta-analysis. PLoS One. 2022;17.
Not in our library10.1371/journal.pone.0272375
17.
Centers for Disease Control and Prevention. 2022.
Not in our library
18.
Merced-Morales A. Influenza activity and composition of the 2022–23 influenza vaccine — United States, 2021–22 season. MMWR Morb Mortal Wkly Rep. 2022;71:913-919.
Not in our library10.15585/mmwr.mm7129a1
19.
CDC. 2021.
Not in our library
20.
Rubin R. Influenza's unprecedented low profile during COVID-19 pandemic leaves experts wondering what this flu season has in store. JAMA. 2021;326:899-900.
Not in our library10.1001/jama.2021.14131
21.
Groves H.E., Papenburg J., Mehta K., et al. The effect of the COVID-19 pandemic on influenza-related hospitalization, intensive care admission and mortality in children in Canada: a population-based study. Lancet Reg Health Am. 2022;7.
Not in our library10.1016/j.lana.2021.100132
22.
Jain R., Dupas P. The effects of India's COVID-19 lockdown on critical non-COVID health care and outcomes: evidence from dialysis patients. Soc Sci Med. 2022;296.
Not in our library10.1016/j.socscimed.2022.114762
23.
Wartelle A., Mourad-Chehade F., Yalaoui F., Chrusciel J., Laplanche D., Sanchez S. Effect of the COVID-19 pandemic lockdown on non-COVID-19 emergency department visits in Eastern France: reduced risk or avoidance behavior? Public Health Pract (Oxf). 2021;2.
Not in our library10.1016/j.puhip.2021.100109
24.
Self-medication practices to prevent or manage COVID-19: A systematic review. · 2021
Not checked
25.
Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis. · 2021
Not checked
26.
Off-season RSV epidemics in Australia after easing of COVID-19 restrictions · 2022
No notice
27.
Mosscrop L.G., Williams T.C., Tregoning J.S. Respiratory syncytial virus after the SARS-CoV-2 pandemic — what next? Nat Rev Immunol. 2022;22(10):1-2.
Not in our library10.1038/s41577-022-00764-7
28.
Amar S., Avni Y.S., O'Rourke N., Michael T. Prevalence of common infectious diseases after COVID-19 vaccination and easing of pandemic restrictions in Israel. JAMA Netw Open. 2022;5.
Not in our library10.1001/jamanetworkopen.2021.46175
29.
Shet A., Carr K., Danovaro-Holliday M.C., et al. Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories. Lancet Glob Health. 2022;10:e186-e194.
Not in our library10.1016/s2214-109x(21)00512-x
30.
Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection · 2020
Corrected
31.
Estimating global and regional disruptions to routine childhood vaccine coverage during the COVID-19 pandemic in 2020: a modelling study · 2021
No notice
32.
Summan A., Nandi A., Shet A., Laxminarayan R. The effect of the COVID-19 pandemic on routine childhood immunization coverage and timeliness in India: retrospective analysis of the National Family Health Survey of 2019–2021 data. Lancet Reg Health Southeast Asia. 2022;8.
Not in our library10.1016/j.lansea.2022.100099
33.
IQVIA. MIDAS database. 2022.
Not in our library
34.
Ritchie H., Mathieu E., Rodés-Guirao L., et al. Coronavirus pandemic (COVID-19). Our world in data. 2020.
Not in our library
35.
Dong E., Du H., Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020;20:533-534.
Not in our library10.1016/s1473-3099(20)30120-1
36.
Dong E., Ratcliff J., Goyea T.D., et al. The Johns Hopkins university center for systems science and engineering COVID-19 dashboard: data collection process, challenges faced, and lessons learned. Lancet Infect Dis. 2022;22(12):e370-e376.
Not in our library10.1016/s1473-3099(22)00434-0
37.
Wooldridge J.M. 2010.
Not in our library
38.
Sun L., Klein E.Y., Laxminarayan R. Seasonality and temporal correlation between community antibiotic use and resistance in the United States. Clin Infect Dis. 2012;55:687-694.
Not in our library10.1093/cid/cis509
39.
Adebisi Y.A., Jimoh N.D., Ogunkola I.O., et al. The use of antibiotics in COVID-19 management: a rapid review of national treatment guidelines in 10 African countries. Trop Med Health. 2021;49:51.
Not in our library10.1186/s41182-021-00344-w
40.
Lewnard J.A., Lo N.C., Arinaminpathy N., Frost I., Laxminarayan R. Childhood vaccines and antibiotic use in low- and middle-income countries. Nature. 2020;581:94-99.
Not in our library10.1038/s41586-020-2238-4
41.
Buehrle D.J., Nguyen M.H., Wagener M.M., Clancy C.J. Impact of the coronavirus disease 2019 pandemic on outpatient antibiotic prescriptions in the United States. Open Forum Infect Dis. 2020;7:ofaa575.
Not in our library10.1093/ofid/ofaa575
42.
Buehrle D.J., Wagener M.M., Nguyen M.H., Clancy C.J. Trends in outpatient antibiotic prescriptions in the United States during the COVID-19 pandemic in 2020. JAMA Netw Open. 2021;4.
Not in our library10.1001/jamanetworkopen.2021.26114
43.
Knight B.D., Shurgold J., Smith G., et al. The impact of COVID-19 on community antibiotic use in Canada: an ecological study. Clin Microbiol Infect. 2022;28:426-432.
Not in our library10.1016/j.cmi.2021.10.013
44.
Klein E., Schueller E., Tseng K.K., Nandi A. The impact of influenza vaccination on antibiotic use in the United States, 2010–2017. Open Forum Infect Dis. 2020;7:ofaa223.
Not in our library10.1093/ofid/ofaa223
45.
International Monetary Fund. 2020.
Not in our library
46.
Obolski U., Kassem E., Na’amnih W., Tannous S., Kagan V., Muhsen K. Unnecessary antibiotic treatment of children hospitalised with respiratory syncytial virus (RSV) bronchiolitis: risk factors and prescription patterns. J Glob Antimicrob Resist. 2021;27:303-308.
Not in our library10.1016/j.jgar.2021.10.015
47.
Rusic D., Vilovic M., Bukic J., et al. Implications of COVID-19 pandemic on the emergence of antimicrobial resistance: adjusting the response to future outbreaks. Life (Basel). 2021;11:220.
Not in our library10.3390/life11030220
48.
Lai C.-C., Chen S.-Y., Ko W.-C., Hsueh P.-R. Increased antimicrobial resistance during the COVID-19 pandemic. Int J Antimicrob Agents. 2021;57.
Not in our library10.1016/j.ijantimicag.2021.106324
49.
Hsu J. How covid-19 is accelerating the threat of antimicrobial resistance. BMJ. 2020;369:m1983.
Not in our library10.1136/bmj.m1983
50.
Founou R.C., Blocker A.J., Noubom M., et al. The COVID-19 pandemic: a threat to antimicrobial resistance containment. Future Sci OA. 2021;7:FSO736.
Not in our library10.2144/fsoa-2021-0012
51.
Immunological characteristics govern the transition of COVID-19 to endemicity · 2021
No notice
52.
World Health Organization. 14.9 million excess deaths associated with the COVID-19 pandemic in 2020 and 2021. 2022.
Not in our library
53.
Irons N.J., Raftery A.E. Estimating SARS-CoV-2 infections from deaths, confirmed cases, tests, and random surveys. Proc Natl Acad Sci U S A. 2021;118.
Not in our library10.1073/pnas.2103272118
54.
Lau H., Khosrawipour T., Kocbach P., Ichii H., Bania J., Khosrawipour V. Evaluating the massive underreporting and undertesting of COVID-19 cases in multiple global epicenters. Pulmonology. 2021;27:110-115.
Not in our library10.1016/j.pulmoe.2020.05.015

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