Even with this sudden increase in awareness of the difference between these two organisms, and why antibiotics worked against one but not the other, antibiotic prescribing went through the roof during the first couple of years of the pandemic.
The World Health Organization reported that while only eight percent of people globally hospitalised with Covid-19 had bacterial co-infections that warranted antibiotic treatment, around 75 percent were given antibiotics anyway, ‘just in case’.
Before SARS-CoV-2 vaccines and effective antiviral drugs were widely available, and before rapid diagnostics emerged to help confirm viral infection, desperation drove prescribing of drugs that were highly unlikely to have any positive impact.
That, in turn, drove an increase in antimicrobial resistance. One analysis found that nearly one-quarter of patients with a bacterial co-infection alongside Covid-19 were carrying bacteria with antimicrobial resistance.
Global change in use
But that misuse wasn’t evenly distributed around the world: antibiotic prescriptions increased in Africa, but decreased in Europe and the Americas.
Antibiotic use also dropped in Australia. The Australian Commission on Safety and Quality in Health Care reported a 40 percent drop in the volume of antibiotics dispensed on the Pharmaceutical Benefits Scheme in April 2020, when most of Australia went into lockdown. Prescriptions stayed well below pre-pandemic levels until the end of 2020.
It’s tempting to assume this drop was because people weren’t visiting their GP as frequently. But the number of GP visits during the first year of the pandemic and lockdowns didn’t drop dramatically enough to explain the reduction in antibiotic prescribing.
Overall, 85 percent of Australians still visited a GP at least once during 2020-2021, down from 88 percent in 2019-2020, and nearly one-third of those consultations were shifted to telehealth.
What is interesting about the drop in antibiotic prescription was that it was predominantly seen in antibiotics prescribed for upper respiratory tract infections: amoxicillin, amoxicillin–clavulanic acid, cefalexin, clarithromycin, doxycycline, phenoxymethylpenicillin and roxithromycin. Antibiotics used to treat non-respiratory conditions showed no change in prescriptions during that same period.
According to antimicrobial stewardship pharmacist Dr Minyon Avent, from the University of Queensland, lockdowns not only curbed the spread of SARS-CoV-2, but a lot of other pathogens as well. “That could be attributed to people not moving around, so our influenza and respiratory tract infections were at an unprecedented low, excluding COVID,” she says.
This is where it gets interesting. “We know that there’s a very high inappropriate prescribing for antibiotics in acute respiratory tract infections, where for most of them the cause is viral and it really doesn’t shorten the duration of the symptoms or the infection,” Dr Avent says. So with far fewer cases of viral respiratory infection, that meant that it had the added benefit of curbing this inappropriate prescribing of antibiotics.
“During the lockdowns, especially in Victoria – which of course had the most stringent – the hospitalisations with infection went down markedly, especially in children – who are something of a canary in the coal mine for infections overall,” Professor David Burgner, a paediatric infectious diseases physician at the Murdoch Children’s Research Institute in Melbourne.
A study that Professor Burgner was involved with supports this notion. He and colleagues looked at national antibiotic dispensing trends from November 2015 to October 2020, and saw a 36 percent drop in dispensings from April 2020 onwards, mostly for antibiotics used to treat respiratory infections.
In particular, the number of antibiotics prescribed by GPs dropped by 42 percent over April-October 2020 compared to the same period in 2019. They also saw a huge drop in antibiotic prescriptions in children. “Reductions from April onwards were seen in all states and territories, but Victoria showed lower dispensing rates after July, coinciding with more stringent lockdowns,” he says.
Antibiotic prescribing patterns in hospitals in Australia also changed as a result of the Covid-19 pandemic. The proportion of antibiotics prescribed in hospitals for pneumonia and for chronic obstructive pulmonary disease both dropped by about one-third, from 2019 to 2020. However this was attributed more to drops in the incidence of both these infections turning up in hospital, likely because lockdowns reduced the overall levels of infections in the community.
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“[The] whole mindset of the public needs to change.”
Dr Minyon Avent
Rethinking reliance on antibiotics
The pandemic clearly illustrated what has been an ongoing issue in Australia, which has been the subject of countless awareness and education campaigns both among GPs and the general public. “It was a natural experiment on many fronts,” says Professor Burgner. “You pretty much turn off the tap of predominantly viral respiratory infections, and you see that concomitant fall-off about the same magnitude of respiratory antibiotics.”
So what effect did these declines have on levels of antimicrobial resistance? Dr Avent says it’s likely that we won’t see a significant effect, because not only have antibiotic prescriptions increased almost back to pre-pandemic levels, but it may also be too soon to see if the drop did reduce resistance levels in the community. “The way we do our monitoring of resistance in Australia, we don’t really have a good surveillance program,” she says.
With a major flu season threatening Australia in 2025, Dr Avent says the findings reinforce the importance of vaccination to prevent respiratory infection – and potentially inappropriate use of antibiotics – in the first place. It also challenges Australians to rethink their attitude to antibiotics, given we have one of the highest levels of use of antibiotics among high-income nations. “It’s really that culture or love affair that Australians have with antibiotics, that they can basically cure anything and everything,” she says. “That whole mindset of the public needs to change.”
Bianca Nogrady is an award-winning science journalist whose reporting on science, health and the environment.
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