Antimicrobial consumption in patients with COVID-19: a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram of the process of study selection.

Table 1. Search strategy

Database	Key Search Terms	Results	Criteria
MEDLINE	antibiotic consumption OR antimicrobial consumption OR antibiotic use OR antimicrobial use And antibiotic or antimicrobial prescribing AND covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19	1124	Full-text article. Only in English Human Dec 2019 to July 2021
CINAHL	antibiotic consumption OR antimicrobial consumption OR antibiotic use OR antimicrobial use And antibiotic or antimicrobial prescribing AND covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19	95	Full-text articles (Journal articles, RCT, Observational studies, Preprint) Only in English Human Dec 2019 to July 2021
WHO- COVID-19 Global literature on coronavirus disease including EMBASE, Scopus, WHO-COVID and LILACS	antibiotic consumption or antibiotic use or antibiotic or antimicrobial prescribing	436	RCT, Observational study. Only English December 2020 to July 2021
Google Scholar	For additional articles	16	RCT, Observational study. Only English

Table 2. Summary of studies examining antimicrobial consumption during the COVID-19 pandemic or among COVID-19 patients

Authors, year	Country	Study design & Setting	Population	Age	Sample size	PCR testing	Severity of Disease	Outcome measures	Key findings
Tan et al, 2021 [28]	Singapore	Global-PPS-survey conduct in hospital (April 2020).	544 confirmed COVID-19 patients	Median age: 45.5 years	577	yes	NA NS	Antibiotic consumption in frequency and percentage.	Antimicrobial consumption: only 36 patients were on antimicrobials at the time of the survey. Antimicrobial prescription: 51 prescriptions were evaluated; 39% (20/51) were inappropriate and 61% (31/51) were appropriate. Common inappropriate antimicrobials prescribed are co-amoxiclav (PO = 50% & IV = 15%), clarithromycin (PO = 20%).
Martinez-Guerra, et al, 2021 [54]	Mexico	Prospective cohort study in a tertiary care center between March 20th and June 10th, 2020.	Patients admitted with severe COVID-19.	Median age 52 years	794; Male:489, Female: 305	yes	Severe; 100%	Antibiotic consumption in frequency and percentage.	731 patients received empirical therapy Common antimicrobials consumed: amoxicillin/-clavulanate plus atypical coverage in 47% patients and ceftriaxone plus atypical coverage in 29% of patients. Extensive use of azithromycin or clarithromycin as atypical coverage was observed i.e. 90%.
Ng et al, 2021 [29]	Singapore	Global-PPS retrospective study in tertiary care hospital (from 2015–2020). Survey was carried out on 4 July 2020	199 COVID-19-positive patients.	Median age: 78 years	8952	NS	NS	Antibiotic consumption in Daily Defined Dose (DDD) per 1000 patient days.	Antimicrobial utilization significantly reduced in previous years; 55% to 49% from 2015 to 2019 and 47% in 2020. Antimicrobial utilization = 1849.71 DDD/1000 patient days at the time of survey. Before the pandemic there was a marked decrease in antimicrobial consumption 361.46 DDD/1000 patients days reported.
Grau et al, 2021 [30]	Spain	Retrospective quasi-experimental study at a tertiary care hospital PPP: January 2018 – February 2020 PP: March – June 2020.	PPP: non-COVID-19- patients PP: COVID-19- patients.	Not specified	PPP: 49069 PP: 386	NS	NS	Antibiotic consumption in DDD)/100 bed days.	An increase was observed in most of the studied antimicrobials. An increase in ceftriaxone of 18.39 DDD/ 100 bed-days and azithromycin 63.129 DDD/100 bed-days was observed during March 2020. Incremental consumption of daptomycin 11.147 DDD/ 100 bed days, carbapenems 12.74 DDD/ 100 bed days, linezolid 13.725 DDD/100 bed days reported during April to May 2020.
Hamidi & Yilmaz, 2021 [6]	Turkey	Retrospective cohort study in tertiary university hospital in Istanbul PPP: January – February 2020 PP: March- April 2020.	PPP: non-COVID-19-patients, PP: COVID-19 Patients.	Not specified	PPP: 5941 PP: 3144	NS	NS	Antibiotic consumption measured in anatomical therapeutic chemical/defined daily dose (ATC/DDD) per 1000 inpatient days	Antimicrobial consumption: overall, DDD = 725.8 during PPP; DDD = 811.4 in PP. PP: increase in antimicrobial consumption observed. Common antimicrobials consumed: ceftriaxone DDD/1000 inpatient days = 224.6 in PP compared with 199.6 in PPP, tazobactam/piperacillin DDD/1000 inpatient days = 63.6 in PP compared with 35.5 in PPP, meropenem DDD/1000 inpatient days = 86.4 in PP compared with 65.1 in PPP.
Zhu et al, 2021 [24]	UK	Primary care setting, data extracted from Whole Systems Integrated Care (WSIC) system covering more than 2 million patients across 400 GP practices in north-west London (NWL). From January 01 to 30 November 2020.	COVID-19 and non-COVID-19-	All	366,059	yes	NS	Antibiotic consumption calculated using the number of items and Defined Daily Dose (DDD) values according to WHO ATC index 2019.	Antibiotic prescribing decreased at a rate of 584 items before March, which was further reduced at a rate of 3504 items per month after March. Despite an overall reduction in prescription, amoxicillin/clavulanic acid prescription was raised by 70.1% ≥50 years of age from February to April 2020. Common antimicrobials: 34.9% of patients were prescribed amoxicillin, 27.4% doxycycline, 9.3% clarithromycin.
Blix & Høye, 2021 [31]	Norway	Retrospective comparative study utilizing wholesale statistics and sales of antibiotics for use outside of healthcare institutions. PPP: January – December 2019 PP: January – December 2020.	All COVID-19-positive patients	All age groups	NS	NS	NS	antibiotics consumption was calculated, DDD/ 1000 inhabitants. Total sales of antibiotics.	Total sales of antibiotics increased by 16% in March 2020 compared to February 2020 and increased by 20% compared to March 2019. 86% increase in azithromycin DDD/1000 inhabitants/day from February 2020 to March 2020 and 93% from March 2019. Total sales for 2020 were 11.5 DDD/ 1000 inhabitants/ day. Between March and April 2020, measured sales in prescriptions/1000 inhabitants fell by 28%.
Fabre et al, 2021 [32]	USA	Multicentre retrospective descriptive observational study (March 01 to 30 May 2020) from five acute care hospitals having 2210 beds.	Patients admitted with a positive molecular SARS-CoV-2.	>18 years Median age: 62 yrs	962; Male: 760, Female: 202	yes	Mild; 79%, Severe; 21%	Antimicrobial consumption in frequency and percentage according to PCT values.	The median DOT for no PCT for CAP = 1.0 days and for low PCT = 4 days, and for high PCT = 3.5 days. Antimicrobials used for CAP were administered to 86% of patients with an initial high PCT (207/241), to 66% of patients with a low initial PCT (246/370), and 66% of patients without a PCT test (234/351). 494 patients without bCAP, out of which 106 (56%) had antimicrobial therapy with no PCT, 116 (57%) with low PCT having antimicrobial therapy & 79 patients having elevated PCT (78%) were having antimicrobial therapy. The median DOT for no PCT for CAP was 1.0 days and low PCT 4 days (p = 0.26) & high PCT 3.5 days.
Rezel-Potts et al, 2021 [25]	UK	Primary care population-based cohort study using the UK Clinical Practice Research Datalink (CPRD) GOLD database (January 2017 to January 2020 as PPP and February to September 2020 as PP).	Non-COVID-19 patients and COVID-19 patients.	All age group	253655 registered patients in 2017 and 232218 in 2020, with 559461 antimicrobialprescriptions,	yes	NS	Antimicrobial consumption in adjusted rate ratios (ARR). The proportion of COVID-19 episodes associated with antimicrobial prescribing.	25,889 COVID-19 patients were identified during PP in which 2942 (11%) had antimicrobial prescription. Compared with pre-pandemic months, March 2020 was associated with higher antimicrobial prescribing (ARR = 1.13 (95% CI = 1.11 to 1.16). Conversely, antimicrobial prescribing fell below predicted rates between April and August 2020, reaching a minimum in May ARR = 0.73 (95% CI = 0.71 to 0.75).
Parveen et al, 2021 [72]	Bangladesh	Cross-sectional study conducted at a tertiary hospital in Dhaka (July 10 to 20 July 2020).	All COVID-19 patients	>18 years	100	yes	Mild: 96% Moderate/Severe/ Critically ill: 4%	Antibiotic consumption in frequency and percentage.	36% of COVID-19 patients were treated with multiple antimicrobials and antivirals simultaneously. 46% of patients had azithromycin, 22% had ivermectin, and 21% of patients were on doxycycline.
Mustafa et al, 2021 [33]	Pakistan	Retrospective cohort study performed in five district hospitals in Punjab. PPP: August 01 to 30 September 2019 PP:August 01 to 30 September 2020.	COVID-19 and non-COVID-19 patients	Mean age of 35.5 years	202; Male: 121, Female: 81	yes	Mild: 54%, Moderate: 33%, Severe: 12%	Antimicrobial consumption, determined as DDD per 100 bed-days.	Antimicrobial consumption was higher in PP compared with PPP; 88.1% of patients were prescribed antimicrobials. Azithromycin DDD/100 bed-days = 17.0 in PP vs 11.5 in PPP; similarly, ceftriaxone DDD = 25.1 vs 20.2, piperacillin/tazobactam DDD = 1.1 vs 0.3, amoxicillin-clavulanic acid 5.1 vs 2.4, ciprofloxacin 3.8 vs 3.5. All prescribed antimicrobials were in the WHO AWaRe Watch category.
Russell et al, 2021 [55]	UK	A prospective cohort study enlisting inpatients from 260 hospitals in England, Scotland, and Wales, conducted by the ISARIC WHO CCP-U, patients admitted to hospital (February 06 to 8 June 2020).	48765 patients with COVID-19 only.	Median age 74 years	48902; Male: 27979, Female: 20786	yes	NS	Antibiotic consumption in frequency and percentage.	85% of 46061 in-patients received one or more antimicrobials at some point during their admission. Amoxicillin, piperacillin-tazobactam, carbapenems, and glycopeptides were the most utilized antimicrobials. The proportion of patients who received antimicrobial in critical care compared with ward-level patients fell or remained static across most regions. A major drop was observed in Scotland in critical care 87 · 2% in March 2020, to 6 · 7% in May 2020, and in the southwest of England in ward-level care 82.7% in March 2020, to 63.9% in May 2020). Amoxicillin was more commonly prescribed in Scotland and Wales, whereas co-amoxiclav prescribed more often in England.
Al-Azzam et al, 2021 [57]	Jordan	Retrospective study obtained data from Jordan FDA from 2019 to 2020.	PPP (2019): Non COVID-19 patients, and PP (2020) COVID-19 patients.	Not specified	PPP: 10,554,000 PP: 10,806,000	NS	NS	Antimicrobial consumption, measured as DDD per 1000 inhabitants per day. The DU90% (drug utilizing) indicator was used to identify the number of antimicrobial accounts for 90% of the use in DDDs.	Antimicrobial consumption: decreased by 5.5% from 2019 to 2020. The total consumed antibiotics was 26.8 in 2020 and 28.4 DDD/1000 inhabitants per day in 2019. The percentage of oral use for 2019 and 2020 was 96% and 94%, respectively. The percentage of IV antimicrobial consumed in 2019 and 2020 was 4% and 6%, respectively. 2020 (compared with 2019): increase in cephalosporin 19%, carbapenems 52%, macrolide 57%; while a decrease in amoxicillin 53%. In 2020, azithromycin consumption increased by 74%, while a significant reduction in amoxicillin use was observed by 53%. In the WHO AWaRe Watch category, there was an increase in consumption of azithromycin from 1.54 DIDs to 2.55 in 2019 and 2020, respectively.
Pettit et al, 2021 [34]	USA	Retrospective, a quasi-experimental single center study in two groups pre-intervention and post intervention (1 March 2020, to 25 April 2020).	COVID-19 patients	Mean age Pre-intervention group: 58 ± 16.2; post-intervention group.: 61 ± 17	506 (102 pre-intervention and 404 post-intervention)	yes	NS	Antimicrobialconsumption, measured in frequency and percentage – the duration of antimicrobial therapy for CABP between two time periods.	246 patients received empirical therapy; 76 in the pre-intervention group and 170 in the post-intervention group. Common antimicrobials consumed in both groups include azithromycin 91% versus 65%, ceftriaxone 84% versus 66%, and cefdinir 66% versus 42%. The median antimicrobial duration of therapy in the postintervention group was 1.3 days; the pre-intervention group was 2.8 days.
Calderon-Parra et al, 2021 [35]	Spain	Retrospective observational cohort study at 150 hospitals (March 01, to 23 June 2020).	COVID-19 patients	≥18 years	13,932	yes	NS	Antibiotic consumption in frequency and percentage.	Antimicrobial prescriptions: appropriate in 44% (6116) patients; inappropriate antimicrobials 34.2% (4769) patients; no antimicrobial 22% (3,047) patients. Systemic antimicrobials other than macrolides were used in 10,885 (78%). The most prescribed antimicrobials were beta-lactams (72%), quinolones (13%), linezolid (2%), glycopeptides (2%), co-trimoxazole (0.6%), and tetracyclines. (0.6%).
Williams et al, 2021 [36]	UK	Retrospective observational study undertaken at Sheffield Teaching Hospitals NHS Foundation Trust (March 05 to 15 April 2020.).	368 COVID-19 patients.	Median age: 75 years.	629; Male: 221, Female: 147	yes	NS	Antibiotic consumption as demonstrated by average DDD of antimicrobials received in the 28-day follow-up period and DDD per day alive over 28 days in correlation with PCT.	Patients in the negative PCT group received significantly fewer DDDs of antimicrobials compared with patients in the positive PCT group (median DDD 3.0 vs. 6.8. AMC: in negative PCT group received significantly fewer median DDD = 3.0; positive PCT group median DDD 3.0. Patients with PCT > 0.25 ng/mL had almost three-fold more DDDs of antimicrobials compared with patients with PCT≤0.25 ng/mL.
Castro-Lopes et al, 2021 [37]	Portugal	A retrospective, descriptive study conducted in the hospital. PPP: 2011 and 2020, PP: March -May 2020	Not specified	All age groups	NS	NS	NS	Antibiotic consumption as annual percentage changes: defined daily doses (DDD)/100 discharges and DDD/100 patient-days).	In Mar-May 2020: antimicrobial consumption increased by 24.2% for discharge patients and 9.7% for patients-days compared with previous years; meropenem consumption was raised by 141% for discharge patients and 113% for patient-days; prophylactic use of cephalosporin decreased by 22.7% for discharge patients and 31.7% for patient days. There was an increase in Access and Watch consumption by 18% and 28% DDD/100 discharge and 4% and 13% DDD/100 patients-days.
Sulis G, et al 2021 [11]	India	The total sales volume of antibiotics, azithromycin, and HCQ were analyzed. Data were obtained from IQVIA India during January 2018 to December 2020.	Non-COVID-19 and COVID-19 patients	NS	NS	NS	NS	The absolute cumulative sale of antibiotics doses.	Antibiotics prescribed and dispensed to adults increased to 77.5% in 2020 from 72.5% in 2019. Total antibiotics sold monthly for adults during the study period (2018–2020) were as follows: “access,” 43.0%; “watch,” 36.8%; “reserve,” 0.8%; and “discouraged,”18.8%. Azithromycin sales (June and September 2020), increased by 34.4%, compared to corresponding months in the previous year. For HCQ in March 2020, increase sales by 11.1 million doses, which decline slowly to significant reduction by 3.1 million doses after September 2020.
Molla et al 2021 [53]	Bangladesh	Global PSS cross-sectional survey conducted at tertiary care hospital on 11 June 2020.	All COVID-19 patients	Median age: 50.44 years	193 Male 134, Female 59	Yes	Moderate: 46.11%, Severe: 53.80%	Antimicrobial prescription patterns assessed in frequency and percentage.	All patients received antimicrobial therapy on the survey day. About 69% (133) of patients received two or more antibiotics, and 31% (60) patients were on a single antibiotic. All prescribed antibiotics were broad-spectrum, 104 (53.88) on ceftriaxone, meropenem 79 (40.9%), moxifloxacin 57 (29.5%), azithromycin 45 (23.3%), doxycline 49 (25.4%).
Moretto et al 2021 [58]	France	Study conducts at Dijon University hospital from February 27 to 30 April 2020.	All COVID-19 patients	Median age:	222 Male 123, Female 99	NS	Mild 8.55%, Moderate 22.9%, Severe 9.9%, critically ill 2.25%	Antibiotic consumption expressed in frequency and percentage.	About 78% (174/222) received antibiotic therapy. The first-line antibiotic therapy was amoxicillin + clavulanate (95, 55%), third-generation cephalosporin with a macrolide (25, 14%) and 27 (16%), respectively.
Buehrle et al, 2020 [39]	USA	Retrospective cohort, hospital-based, single centered study. From November 2017 to June 2020 as monthly data. 16 February to 4 July 2020, weekly data.	Non-COVID-19 and COVID-19 patients.	NS	All adult patients	yes	NS	Antimicrobial consumption, as DOT, DOT/1000 BDOC.	Monthly hospital antimicrobial utilization due to COVID-19 restriction significantly decreased from March to June 2020 compared with previous months. In contrast, overall, DOT/1000 BDOC increased significantly compared to previous months. Antimicrobial DOT and BDOC decreased by weekly averages of 25.6 (5.1% 98 weekly reductions CI: 3.4% to 8.8%). Antimicrobials were administered to 56% (9/16) of patients during hospitalization. 100% (9/9) of patients requiring ICU care received antimicrobials, compared to 0% (0/7) of patients not requiring ICU care. Antimicrobials were prescribed for infections present upon admission or acquired in the hospital.
Townsend et al, 2020 [40]	Ireland	Retrospective single center study (March to April 2020). From March to April 2020.	All COVID-19 patients	Adult Median age: 66 years	117; Male: 74 Female: 43	Yes	Severe: 34.18%	Antimicrobial consumption in frequency and percentage. Median duration of antimicrobial therapy was also calculated along with IV to oral switch.	Antimicrobial prescription: 81% (95/117) within 24 hours of COVID-19 diagnosis. Empirical therapy: 71.7% (84/11)) patients prescribed for respiratory bacterial co-infection either CAP/HAP/VAP; in which 92.85% (78/84) patients had monotherapy. The median duration of antimicrobial therapy was seven days: IV antimicrobial therapy for five days and oral treatment for three days.
Ponce-Alonso et al, 2020 [41]	Spain	Retrospective study at tertiary care hospital. From 11 March to 11 May 2020, with the same period of the previous year (control period).	All COVID-19-patients with CDI included in the study.	Mean age: 66.74 years for the COVID-19 period and 64.41 years for the control period.	2337 confirmed COVID-19 patients, and 283 suspected. COVID-19 period; n = 44831; control period, n = 39795	Yes	NS	Antimicrobial use was measured as DDD/100 occupied bed days and DOT per 100 patient days.	COVID-19 period: antimicrobial consumption increased by DDD = 89.73 DDD vs control period DDD = 79.2. AMC increased in COVID-19 period vs control period; similarly: cephalosporins DDD = 19.4 vs 6.3 DDD, macrolide DDD = 25.5 vs 5.8. AMC declined in COVID-19 period vs control period; similarly: quinolones DDD = 4.61 vs 8.7, inhibitor-penicillin DDD = 16.60 vs 25.7. DOT per 100 patient days was reduced for quinolones and inhibitor-penicillin combinations during the COVID-19 period (3.9 and 17.9) versus the control period (i.e. 8.14 and 27.9), respectively. No relevant differences in the use or treatment duration of carbapenems between the two periods
Guisado-Gil et al, 2020 [56]	Spain	Prospective before-after study at tertiary-care Hospital (Virgen del Rocio). PP: 1–2 quarter of 2020, antimicrobial consumption; PPP: compared to the same quarter of 2019.	Patients in COVID-19 ward and non-COVID-19 ward.	Adult	282	NS	NS	Antibiotic consumption as defined dailydoses per 1000 occupied bed days (OBD).	Antimicrobial utilization increased to 99.4 and 53.1 DDD/1000 OBD in 1st and 2nd quarters during the pandemic period vs. the same quarter in the previous year. During the COVID-19 pandemic (weeks 10–20), the antimicrobial consumption increased by 3.5% per week from the beginning until week 15 (six weeks after national lockdown). From this date until the end of the study period, a sustained weekly reduction of 6.4% was observed. The empirical treatment in COVID-19 patients and pneumonia was 33.7% (95/282 patients).
Zhu et al, 2020 [20]	UK	Primary care prescriptions were analyzed from Jan 2016 to June 2020 involving out-of-hours (OOH) and in-hours (IH) services (January 2016 to June 2020).	COVID-19 and non-COVID-19 patients	All age groups	NS	Yes	NS	The total prescribing volume, prescribing of broad-spectrum anti-microbials were measured in frequency and percentage in OOH setting.	Antimicrobial prescribing (OOH): represented 3.3–3.6% of the total prescriptions from 2016 to 2019. From January 2016 to February 2020, antimicrobial prescribing for IH GPs showed a downward trend, a decrease of 7,329 items per month During the pandemic, according to the number of items measured, penicillin remained the most prescribed antimicrobial group (61.6%) by OOH GPs, followed by tetracyclines (11.2%) and macrolides (10.30%), which were the same as for IH GPs. Each year, the proportion of broad-spectrum antimicrobials (cephalosporins, quinolones, and co-amoxiclav) to the total prescription volume was highest in August, both among IH and OOH GPs. Since March 2020, the proportion of broad-spectrum prescriptions rose in both settings.
Nori et al, 2020 [42]	USA	Retrospective observational study (March 01 to 18 April 2020).	All patients with COVID-19	Median age 62	152; Male: 89 Female:63	Yes	NS	Antibiotics use was measured as DOT.	Antibiotic therapy: 98% (149/152) patients received antimicrobials. 70% (107/152) patients received > 3 antimicrobials including β-lactams, glycopeptides, macrolides, or tetracyclines. The median DOT = 8.5 days (IQR, 5–14); 12 days (IQR, 7–20) in patients with multidrug resistance, and eight days (IQR, 4–14) in patients without infections. Common antimicrobials consumed: azithromycin, ciprofloxacin, ceftriaxone, cefepime doxycycline, levofloxacin, piperacillin/tazobactam, and vancomycin.
Karami et al, 2020 [43]	Netherlands	Retrospective cohort multicentre study (2 March 2020 to 22 May 2020).	All patients with COVID-19	Median: 70	925; Male: 591, Female:334	Yes	NS	Antimicrobial consumption is expressed as the duration of treatment in calendar days.	Antimicrobial therapy: 60.1% (556/925) of patients received antimicrobials for a median duration of 2 days (IQR 1–4). Intravenous to oral switch was performed in 41 of 413 (9.9%) patients who received intravenous treatment >48 h. Treatment duration was ≤ five days in 467 of 555 (84.1%) patients. 490 patients who received antimicrobials >48 h intravenously anytime during the first seven days, intravenous to oral switch happened in 52 (10.6%) patients.
Buehrle et al, 2020 [27]	USA	Monthly prescription filling data were obtained from US-NPA (National Prescription Audit). PPP: August 2014–March 2020 PP: April – July 2020.	Non- COVID-19 and COVID-19 patients.	NS	NS	NS	NS	Antimicrobial prescription fills per 1000 persons were measured in percentages.	August 2014 to March 2020: a substantial reduction in monthly prescription fills per 1000 persons was observed, which included ciprofloxacin, levofloxacin, co-trimoxazole, and clindamycin. In addition, doxycycline, and monthly nitrofurantoin fill per 1000 persons increased, and amoxicillin-clavulanate and cephalexin remained unchanged. In April 2020, significant reductions of 13% to 56% in monthly prescriptions filled per 1000 persons of all ten antimicrobials
King et al, 2020 [9]	USA	Data were taken from IQVIA total patient tracker. (January 2017 to May 2020).	Non COVID-19-patients and COVID-19 patients	All age groups	NS	NS	NS	Prescribing antimicrobials were represented as a percentage point, and volume changes in the number of patients dispensed antimicrobials	From January to May 2020, antimicrobials dispensed decreased from 20.3 million to 9.9 million, a reduction of almost 33% From February to March 2020, azithromycin prescriptions increased by 5%, followed by a 71% decrease from March to May 2020. In April and May 2020, there was a decrease in antimicrobials dispensed of 39% to 42%, respectively.
Rothe et al, 2020 [44]	Germany	Retrospective single-center cohort study (16 February 2020 to 22 April 2020.	COVID-19 hospitalized patients	Adult patients	140; Male: 90, Female: 50	Yes	Moderate: 60%, Severe: 40%	Antimicrobial therapy was measured as DOT., and the median length of hospital stay was associated with the severity of the disease.	Antimicrobial therapy: 82.8% (116/140) of patients received empirical therapy. DOT of common antimicrobial regimen studied; ampicillin/sulbactam (41%) median DOT = 6 days, piperacillin/ tazobactam with or without azithromycin (19%) with a median DOT = 10 days. Combination therapy of meropenem with vancomycin or linezolid (n = 20, 35.1%) was prescribed in more severe cases. In addition, echinocandins were also used, 5 patients (8.8%), voriconazole in 4 patients (7.0%), fluconazole in 6 patients (10.5%), and liposomal amphotericin-B was documented in 8 (14.0%) COVID-19 patient. The Median LOS in severe patients was 19 (1–47) days in comparison with moderate ill patients 10 (1–46) days.
Liu et al, 2020 [21]	China	Retrospective descriptive studies from Jilin, China (January 22 to 15 March 2020).	COVID-19 patients.	Median Age: 43	93; Male: 54, Female:39	yes	Mild: 2.1%, Moderate: 86.0%, Severe: 5.4%, Critically ill: 6.5%	Antimicrobial therapy, measured in frequency and percentage.	Of 93 patients, 84 (90%) patients were treated with antimicrobials, including moxifloxacin 78% (n = 73), levofloxacin in 8.6% (n = 8), doxycycline 6.5% (n = 6), amikacin 6.5% (n = 6), azithromycin 4.3% (n = 4). Out of 93 patients, 64 (68.8%) were treated empirically with a single antimicrobial; moxifloxacin (58%), levofloxacin (5.4%), azithromycin (1.1%), amoxicillin (1.1%), cefepime (1.1%), cefoperazone-sulbactam (1.1%), and cefixime (1.1%).
Easom et al, 2020 [64]	UK	Retrospective descriptive study conducted at the RIDU at Hull University Teaching Hospitals NHS Trust (January 29 to 24 February 2020).	COVID-19 patients	Mean age: 42.5 years	68; Male: 32, female: 36	yes	Ns	Antibiotic consumption in frequency and percentage.	Of 68 COVID-19 patients, 9 received antibiotic therapy (1.3%), with doxycycline given to five patients, moxifloxacin to three, and oseltamivir to one confirmed influenza A case (1%).
Khamis et al, 2020 [65]	Oman	A study conducted at two hospitals in Oman, the Royal Hospital and Al Nahdha Hospital (February 24 to 24 April 2020).	COVID-19 patients	mean age: 48 ± 16	63; Male:53, Female: 10	Yes	NS	Antibiotic consumption in frequency and percentage.	AMC: 79% (50/63) patients received antimicrobial therapy including ceftriaxone (79%; n = 50), azithromycin (71%; n = 45), and piperacillin/tazobactam combination (49%; n = 31). ICU patients were more likely to be prescribed the piperacillin/tazobactam combination (79% vs. 31%) and meropenem (29% vs. 2.6%).
Neto et al, 2021 [50]	USA	Retrospective single‐center study (March 01 to 24 April 2020).	COVID-19 patients.	Mean age: 66 years	389; Male 123, Female 119	Yes	NS	Antimicrobial consumption in frequency and percentage.	AMC: 67% (162/242) patients received antimicrobials. The most common regimen included cefepime (45%), ceftriaxone (54%), vancomycin (48%), and azithromycin (47%). A considerably higher inpatient mortality rate was observed in those who received antimicrobials than those who did not (30% vs. 5%).
Liu et al, 2021 [52]	China	A retrospective study at university hospital Wuhan. Grouped as suspected bacterial infection (SI) and no evidence of bacterial infection (NI) from Jan 26 to Mar18, 2020).	COVID-19 patients	Median age: 61 years.	1123 Male 560, Female 563	Yes	Severe 52.6%	Antimicrobial consumption was reported as frequency and percentage. Antimicrobial consumption was compared in SI and NI groups categorized in the study.	53.5% in SI vs 93.9% NI received antimicrobial therapy. 385 patients received oral antimicrobial therapy, 41.9% SI group vs 28.8% NI group. 53.6% of patients received IV antimicrobial (82.5% in SI group, 32.6% in NI group). Overall, 792/1123 (70.5%) and 958/1123 (85.3%) patients received antimicrobials and antivirals, respectively
Malclom et al 2020 [10]	UK	Weekly data of e-prescription by GP practice from 2 February (week 8) to 31 May 2020 (week 22) compared with same period in previous year (2019).	All patients	NS	NS	NS	NS	Total number of antibiotic GP prescriptions.	Total GP prescriptions in the last week of March were 37052, 44% higher than the same week in 2019. Significant increase in doxycycline and a modest increase in amoxicillin and clarithromycin prescriptions. In the last week of May 2020, 7109 (34%) fewer prescriptions than in 2019. There was a reduction in prescribing of amoxicillin (5151 items, 50%); clarithromycin (1016, 37%); and doxycycline (998, 19%).
Seaton et al 2020 [46]	UK	Global PPS conducted at 15 hospitals on a single day between April 20^th and 30^th, 2020.	COVID-19 (n = 421) and non-COVID-19 patients (n = 277)	Median age: 70 years	820 Male 425, Female 395	Yes	Severe: 14.9%	Antimicrobial prescription expressed in frequency and percentage.	257 (64%) SARS-CoV-2 positive patients received antibiotics on admission 51.9% of COVID-19 positive patients received IV antibiotics, and 95% were empirical therapy. On the day of the survey, 36.3% of COVID-19 positive patients were on antibiotics (153/421) Amoxicillin (107, 21.9%), doxycycline (16.6%), and co-amoxiclav (12.7%) were the most prescribed antibiotics, accounting for more than 50% of all antibiotics on the survey day.
Stevens et al 2021 [47]	USA	A retrospective study conducted at tertiary care center, Minnesota between March 01 to 28 April 2020.	COVID-19 patients	Median age: 45 years	346 Male 170, Female 176	Yes	Mild: 2.02%, Moderate:4.9%, Severe: 4.3%	Antimicrobial consumption was determined by overall prescribing rate, days of therapy (DOT), DOT per antimicrobial day and duration of therapy.	Rate of antimicrobial prescription was lower in ambulatory care (3%) than in-patients 10%, and the mean duration of therapy for inpatients vs ambulatory care was 6.3 days and 5.7 days, respectively. The average DOT per antimicrobial day for all inpatients was 1.65: 1.18 for mild cases, 1.29 for moderate cases, and 1.84 for severe cases, respectively. Common antibiotics prescribed in inpatients were azithromycin, ceftriaxone, cefepime and azithromycin, cefdinir, and penicillin in ambulatory care.
Evans et al 2021 [59]	UK	An observational study conducted at St George’s Hospital, London between April 01 to 25 April 2020.	COVID-19 patients	Median age: 67 years	130 Male 79, Female 51	Yes	24% severe, 76% mild/ moderate	The antibiotic consumption was expressed as antibiotic prescription in percentages.	About 90% received antibiotics on admission; antibiotics were escalated in 13% of patients 56% of patients received dual therapy either with benzylpenicillin or amoxicillin in combination with doxycycline or clarithromycin. On the ward, 7% of patients were prescribed quinolone and cefuroxime. The median duration of antibiotic therapy was seven days inwards and three days in ICUs.
Vaughn et al 2021 [60]	USA	A randomly sampled cohort of hospitalized patients at 38 Michigan hospitals between March 13 to 6 June 2020.	COVID-19 patients	Median age: 64.7 years	1705 Male885, Female 820	Yes	NS	The percentage of empirical prescribed antibiotics, antibacterial use (daily inpatient utilization as day/1000 patients)	About 57% (965/1705) of patients received empirical antibacterial therapy. The most prescribed antibacterial were ceftriaxone 38.9% (663/1705), vancomycin 3.8% (235/1705), doxycycline 10.9% (185/1705), and cefepime 10.4% (177/1705). Total days of inpatient, post-discharge, and total antibacterial therapy were 4158 days/1000 patients, 484 days/1000 patients, and 4628 days/1000 patients, respectively
Dieringer et al 2021 [48]	USA	A retrospective study, data were extracted from VA Corporate Data Warehouse between January-May from 2015 to 2020.	Non-COVID-19 patients and COVID-19 patients	NS	NS	NS	NS	Antibiotic use determined as days of therapy (DOT) per 1000 days present (DP).	Antibiotic utilization from January to May decreased from 638 to 602 DOT per 1,000 DP (mean decrease,9.1 DOT per 1,000 DP per year) between 2015 to 2019. In comparison, antibiotic use increased from 602 to 628 DOT per 1,000 DP in the same period. Broad-spectrum agents used for community-onset infections (9.1 DOT per 1,000 DP), and broad-spectrum agents used for hospital-onset infections (7.5 DOT per 1,000 DP). Substantial rises in the antibiotic use observed (DOT per 1,000 DP) for ceftriaxone (14.7 DOT per 1,000 DP), cefepime (10.5 DOT per 1,000 DP), doxycycline (6.2 DOT) per 1,000 DP), and azithromycin (6.2 DOT per 1,000 DP).
Staub et al 2021 [49]	USA	Retrospective observational study conducted at tertiary care center between Pre-COVID and during COVID-19.	Non-COVID-19 and COVID-19 patients (n = 131)	Median age 56 years (COVID-19 patients only)	131 COVID patient Male 79, Female 52	Yes	NS	Antimicrobial use was calculated as days of therapy per 1,000 patient days present (DOT per 1,000 days).	Of 131 (55.0%) patients with confirmed COVID-19, 86 (65.6%) received antimicrobial. Compared to the PPP, an initial increase in weekly antimicrobial use of 145.3 DOT per 1,000 days was observed at the ward level. Similarly, in ICUs, an initial weekly increase in antimicrobials of 204.0 antibiotic DOT per 1,000, followed by a decline in weekly antimicrobial use of 226.3 antibiotic DOT per 1,000 days. A significant weekly increase of 48.7 DOT per 1,000 days for azithromycin and 47.9 DOT per 1,000 days for ceftriaxone in the first weeks of COVID-19, followed by a significant weekly decrease in azithromycin use of 58.2 DOT per 1,000 days and an increase in ceftriaxone use of 13.6 DOT per 1,000 days in the second post–COVID-19 period
Mustafa et al 2021 [62]	Kosovo	The analytical and observational study conducted at University Hospital in Pristina.	COVID-19 patients	Median age: 61 years	52 Male 35, Female 17	Yes	Severe: 78.8%	Antibiotic prescription was determined as the duration of treatment, frequency, and percentage.	Empirical antibiotic treatment was prescribed in 48 (92.3%) patients before admission to the ICU. Antibiotics were prescribed to 13 patients (25%) before hospitalization, 49 patients (94.2%) in the ward, and all patients in the ICU. Before ICU admission, the common antibiotics prescribed were ceftriaxone/cefotaxime plus macrolide (17 cases; 32.7%), ceftriaxone/cefotaxime (15 cases; 28.8%), co-amoxiclav (6 cases; 11.5%), levofloxacin in (4 cases; 7.7%), co-amoxiclav plus macrolide (3 cases; 5.8%), co-amoxiclav plus fluoroquinolone (3 cases; 5.8%), and another antibiotic (not specified) in one case (1.9%). While in ICU, imipenem was the most frequently used (30 cases; 57.7%), followed by ceftriaxone (28 cases; 53.8%), fluoroquinolone (22 cases; 42.3%), piperacillin/tazobactam (17 cases; 32.7%), ceftazidime (3 cases; 5.7%) and meropenem (1 case; 1.9%). The mean duration of antibiotic treatment for the ICU patients was 12.71 days 18 (34.6%) were on triple therapy, 29 (55.8%) were on dual therapy, and only 5 (9.6%) patients received single-agent antibiotic therapy.

Figure 2. Quality assessment of included observational studies using Newcastle-Ottawa scale.

This figure was corrected for one minor error- please note that there is no need to be colour figure (we are ok with the following the journal policy).

Figure 3. Pooled antimicrobial consumption estimate (%) in COVID-19 patients (Heterogeneity: I² = 100%; p = 0.001).

This figure was corrected for one minor error- please note that there is no need to be colour figure (we are ok with the following the journal policy).

Figure 4. Pooled proportion of COVID-19 patients prescribed an antibiotic in high-income countries.

This figure was corrected for one minor error- please note that there is no need to be colour figure (we are ok with the following the journal policy).

Figure 5. Pooled proportion of COVID-19 patients prescribed an antibiotic in low-middle income countries [NS: Not Specified, AMC: Antimicrobial/ antibiotic consumption, PPS: Point Prevalence Survey, PO: Per Oral, IV: Intravenous, WHO ATC: World Health Organization Anatomical Therapeutic Chemical, DDD: Defined Daily Dose, PPP: Pre-Pandemic Period, PP: Pandemic Period, ICU: Intensive Care Unit, CABP: Community-Acquired Bacterial Pneumonia, BDOC: Bed Days of Care, CAP: Community-Acquired Pneumonia, bCAP: Bacterial-Community Acquired Pneumonia, HAP/VAP: Hospital-Acquired Pneumonia/ Ventilator-Associated Pneumonia, PCT: Procalcitonin, SI: Suspected bacterial infection, NI: No evidence of bacterial infection. LRTI: Lower Respiratory Tract Infection, HCFA – CDI: Healthcare Facility-Associated Clostridioides Difficile Infection, CLABI: Central Line-Associated Bloodstream Infection, IQR: Interquartile Range, HCQ: Hydroxychloroquine, DP: Days Present].

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