COVID-19 and Outpatient Antibiotic Prescriptions in the United States: A County-Level Analysis

Abstract

Background: Declines in outpatient antibiotic prescribing were reported during the beginning of the coronavirus disease 2019 (COVID-19) pandemic in the United States; however, the overall impact of COVID-19 cases on antibiotic prescribing remains unclear.

Methods: This was an ecological study using random-effects panel regression of monthly reported COVID-19 county case and antibiotic prescription data, controlling for seasonality, urbanicity, health care access, nonpharmaceutical interventions (NPIs), and sociodemographic factors.

Results: Antibiotic prescribing fell 26.8% in 2020 compared with prior years. Each 1% increase in county-level monthly COVID-19 cases was associated with a 0.009% (95% CI, 0.007% to 0.012%; P < .01) increase in prescriptions per 100 000 population dispensed to all ages and a 0.012% (95% CI, -0.017% to -0.008%; P < .01) decrease in prescriptions per 100 000 children. Counties with schools open for in-person instruction were associated with a 0.044% (95% CI, 0.024% to 0.065%; P < .01) increase in prescriptions per 100 000 children compared with counties that closed schools. Internal movement restrictions and requiring facemasks were also associated with lower prescribing among children.

Conclusions: The positive association of COVID-19 cases with prescribing for all ages and the negative association for children indicate that increases in prescribing occurred primarily among adults. The rarity of bacterial coinfection in COVID-19 patients suggests that a fraction of these prescriptions may have been inappropriate. Facemasks and school closures were correlated with reductions in prescribing among children, possibly due to the prevention of other upper respiratory infections. The strongest predictors of prescribing were prior years' prescribing trends, suggesting the possibility that behavioral norms are an important driver of prescribing practices.

Keywords: antimicrobial stewardship; ‌antibiotic resistance; ‌behavioral norms; ‌non-pharmaceutical interventions; ‌respiratory infections.

Figure 1.

Number of antibiotic prescriptions dispensed per 100 000 population from 2017–2020. A, Total antibiotic prescriptions dispensed per 100 000 population by month for each year from 2017–2020. B, Total percent change in antibiotic prescriptions dispensed from the mean number of antibiotic prescriptions dispensed per 100 000 population in 2017–2019 compared with 2020 by state.

Figure 2.

Number of antibiotic prescriptions dispensed per 100 000 population in 2020 vs 2017–2019 average by antibiotic class and age group. A, Mean number of antibiotic prescriptions dispensed per 100 000 population for the most widely used antibiotic classes from 2017–2019 compared with the number of antibiotic prescriptions dispensed per 100 000 population for the same classes in 2020. B, Mean number of antibiotic prescriptions dispensed per 100 000 population by age group from 2017–2019 compared with the number of antibiotic prescriptions dispensed per 100 000 population for the same age groups in 2020.