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We thank Bassetti and colleagues for their review on the challenge of appropriate antibiotic prescribing in hospitalized patients with COVID-19 [Citation1]. The authors discuss the role of vaccination and case mix as important factors explaining the observed decline in the prevalence of antibiotic use among hospitalized patients with COVID-19 toward the latter phase of the pandemic. Indeed, we have evidence that antibiotic use in patients hospitalized with COVID-19 was highly dynamic throughout the pandemic in Hong Kong.
Using electronic health records that included data on all COVID-19 hospitalizations in Hong Kong, we estimated the prevalence of antibiotic prescribing among 65,810 hospitalized patients with COVID-19 throughout five pandemic waves [Citation2] Somewhat surprisingly, the prevalence initially declined during the first four waves and then peaked, late in the pandemic, at 65% during the early Omicron wave (January to late May 2022). The prevalence of antibiotic use subsequently declined to 43% (late May to September 2022) but still remains well above the estimated prevalence of confirmed bacterial co-infections at 7% [Citation3].
In addition to other pre-admission characteristics, we could also assess the potential impact of COVID-19 vaccination status on antibiotic prescriptions during admission, since our data were linked to territory-wide individual records of COVID-19 vaccination. Our analysis indicated a strong and graded association for age, COVID-19 disease severity, and the number of COVID-19 vaccine doses with the receipt of an inpatient antibiotic prescription. For example, the odds ratio for 4 doses versus 0 doses of COVID-19 vaccine was 0.52 (95% confidence interval: 0.44 to 0.62). This strong association suggests that COVID-19 vaccines might have a key role to play in not only preventing severe disease and death, but also by reducing antibiotic use in COVID-19 inpatients.
When interpreting the results of systematic reviews on the prevalence of antibiotic use, we urge a cautious approach to analyses showing very high between-study heterogeneity in the studies cited by Bassetti et al [Citation4,Citation5]. Furthermore, within-study heterogeneity would also be present and a reported overall prevalence of antibiotic prescribing can certainly mask differences amongst important patient sub-groups. For example, in our study, we observed a strong relationship between antibiotic prescription and patient age and disease severity [Citation2]. When stratified by age group, the antibiotic prescribing prevalence varied widely: 10% for <20 years, 34% for 20–59 years, 59% for 60–79 years and 80% for ≥80 years. When examining disease severity, nearly all patients (96%) with COVID-19 who experienced a fatal outcome (defined as in-hospital death) were prescribed an antibiotic whereas the prevalence was only 34% among patients with mild-to-moderate disease severity. However, there is a lack of data on the occurrence of bacterial co-infections among specific patient groups, although the reported overall prevalence of bacterial infections was much lower than the overall prevalence of antibiotic use in patients with COVID-19. Therefore, detailed analyses that consider key patient characteristics are required to better understand antibiotic use in hospitalized patients with COVID-19.
We agree that a renewed emphasis on antimicrobial stewardship is required for clinicians and hospitals. Finally, actionable evidence-based recommendations are urgently needed to reduce inappropriate antibiotic prescribing in hospitalized patients with COVID-19.
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
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References
- Bassetti M, Brucci G, Vena A, et al. Use of antibiotics in hospitalized patients with COVID-19: evolving concepts in a highly dynamic antimicrobial stewardship scenario. Expert Opin Pharmacother. 2023;24(15):1679–1684. doi: 10.1080/14656566.2023.2239154
- Blais JE, Zhang W, Lin Y, et al. Antibiotic use in hospitalized patients with COVID-19: a population-based study in Hong Kong. Antimicrob Steward Healthc Epidemiol. 2023;3(1). doi: 10.1017/ash.2023.485
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