Timothy Gauthier, PharmD, BCSP, BCIDP, introduced the APhA2023 session by summarizing current clinical studies and how antibiotic use has evolved since the onset of the COVID-19 pandemic, explaining risk factors for multidrug-resistant organisms. He also compared the impact of COVID-19 on antibiotic resistance based upon a review of antibiograms and identified strategies to mitigate drug resistance using an interdisciplinary team-based approach.
Dr. Gauthier spoke on the early days of the COVID-19 pandemic and the uncertainty surrounding the experimental medications that would be used to combat it. A few of the medications mentioned were the possible use of hydroxychloroquine and azithromycin, but he noted that “there was no proven therapy to fight COVID” at that time, and remarked, “We didn’t know how bad this would get for us and our patients.”
Dr. Gauthier compared more recently updated sites, such as the National Institutes of Health (NIH)’s COVID-19 Treatment Guidelines and the Administration for Strategic Preparedness & Response’s website, which provides the FDA’s authorization information, as well as fact sheets for healthcare providers, patients, and caregivers on medications used for COVID-19 treatment, such as Paxlovid. The NIH ultimately decided against the use of antibacterial therapy (e.g., azithromycin, doxycycline) and hydroxychloroquine for the treatment of COVID-19.
He noted a significant decrease (31%) in outpatient antibiotic prescriptions filled in 2020, according to a 2021 study published in the Journal of the American Medical Association. The largest reductions were seen in prescriptions for amoxicillin, amoxicillin/clavulanic acid, azithromycin, doxycycline, cephalexin, and ciprofloxacin. The driver for the decrease was unknown, but he noted that the researchers concluded “COVID-19 had an attack” on it. Another study concluded, “Outpatient antibiotic prescribing reductions were driven less by antibiotic prescribing for respiratory indications and largely explained by decreased visits for respiratory infections.” He added, “People still had infections…and one of the things we see is that people generally did not want to go to the ER [emergency room].”
Medicare patients who were going to urgent care centers for COVID-19 symptoms had the highest azithromycin prescription rate—with 50% of them leaving with a prescription for that drug. With the “unnecessary” azithromycin prescribing to COVID-19 patients, Dr. Gauthier stressed that “We need to be engaged to ensure that we’re not doing that.” He says that some of the drivers of inappropriate antibiotic use included:
• Clinical uncertainty (i.e., lack of necessary tools/resources and knowledge)
• Lack of guidelines/antimicrobial stewardship workflow deficiencies
• Fear of missing a diagnosis and having a bad patient outcome
• Fear of getting low patient satisfaction scores
• Fear of litigation.
Regarding antibiotic resistance associated with the COVID-19 pandemic, Dr. Gauthier noted another study based on the World Health Organization research database in 2022. The study included a meta-analysis of 23 studies, of which 89% were from hospital settings. The researchers concluded that COVID-19 may have impacted resistance emergence (particularly in gram-negative organisms), but there was considerable heterogeneity in both the antimicrobial resistance metrics utilized and the rate of resistance reported across studies.
Dr. Gauthier noted that with antibiograms, “Changes in resistance can be slow, so it could take 4 or 5 years of resistance to change bug-drug combinations.” He said that it would be difficult to categorize “meaningful changes,” adding that laboratory testing and reporting standards change yearly, and antibiogram methodology often fluctuates over time. He stressed that antibiograms can be a “blunt instrument but still have value.”
As a strategy to mitigate drug resistance using an interdisciplinary team-based approach, Dr. Gauthier proclaimed, “Teamwork makes the dream work. I say this all of the time.”
The Agency for Healthcare Research and Quality has developed “The Four Moments of Antibiotic Decision Making” when making decisions on prescribing antibiotics for patients. The four moment questions are:
• Moment 1: Does my patient have an infection that requires antibiotics?
• Moment 2: Have I ordered appropriate cultures before starting antibiotics and what empiric therapy should I initiate?
• Moment 3: Can I stop, narrow, or change from IV to oral therapy?
• Moment 4: What duration of antibiotic therapy is needed for my patient’s diagnosis?
In closing, Dr. Gauthier summed up the session by noting the following: the progression of antimicrobial resistance is complex; the COVID-19 pandemic has challenged rational use of antibiotics for a new disease state in practice; and interdisciplinary efforts to mitigate unnecessary antimicrobial drug use are needed.
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Published April 17, 2023