Infectious Disease

The health system is seeing a nearly 80% decrease in antibiotics for RTIs amid a pandemic

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Lepak reports that outside of the study, he has received grants from Amplyx, Cidara, Fedora, KBP Biosciences, Matinas, Melinta, Merck, MicuRx, Nosopharm, Paratek, and Wockhardt. Please refer to the study for all relevant financial information from the other authors.


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A “significant drop” in respiratory virus detection correlated with a 79% reduction in ambulatory antibiotic prescribing rates for respiratory infections during the COVID-19 pandemic, researchers wrote a pre-post study.

The trend was observed at the University of Wisconsin (UW) Health, an academic health system with more than 80 outpatient locations and 7,000,000 outpatient encounters per year, the researchers said.

“We saw dramatic decreases in respiratory virus nationwide during the usual respiratory virus season.” Alexander J. Lepak, MD, an infectious disease professor at the University of Wisconsin School of Medicine and Public Health, said Healio Primary Care.

A similar trend can be seen in other geographic areas, he added.

“Unfortunately, because respiratory viruses are one of the most common reasons for prescribing antibiotics in ambulatory settings, we hypothesized that the dramatic decline in respiratory viruses was accompanied by a decline in ambulatory antibiotic prescriptions,” said Lepak. “We thought this was an interesting opportunity to quantify the impact of respiratory viruses on outpatient antibiotic prescribing.”

Lepak and colleagues searched the Wisconsin polymerase chain reaction monitoring data for influenza, respiratory syncytial virus, human parainfluenza virus, human metapneumovirus, seasonal coronavirus, adenovirus, and enterovirus / rhinovirus. They also used an electronic health records tool to analyze changes in respiratory virus detections, antibiotic prescriptions per 1,000 patient exposures, and antibiotic prescriptions for respiratory infections per 1,000 patient exposures. The data was collected from a period before the pandemic (July 2018 to February 2020), a period of 1 month (March 2020) and a period of the COVID-19 pandemic (April 2020 to February).

The researchers reported in JAMA Internal Medicine that the number of outpatient visits during the period before and after the pandemic was similar (637,000 vs. 661,000 monthly; P = 0.24). However, monthly visits related to influenza, RSV, and seasonal coronavirus decreased during the pandemic compared to previous seasons (12 vs. 4,800; P <0.001). Other monthly detections of respiratory viruses also decreased (560 vs. 228; P <0.001).

Although antibiotic prescriptions increased during the pre-pandemic winter respiratory virus season, short-term antibiotic prescribing rates fell during the pandemic and remained low throughout the pandemic, according to the researchers. After adjusting for this seasonality, the monthly antibiotic prescriptions for respiratory infections per 1,000 patients decreased (79%; 10.5 prescriptions vs. 2.2 prescriptions; P <0.001). Non-influenza viruses showed the strongest association with antibiotic prescribing for respiratory infections (r = 0.82; P <0.001).

“This resulted in about 10 fewer antibiotic prescriptions for respiratory infections per 1,000 encounters in our healthcare system, which in our study leads to almost 80,000 fewer prescriptions during the 12-month COVID-19 pandemic period in our study,” Lepak said in an interview.

“We expected a decline, but I admit I did not expect such a dramatic decline,” he continued. “That number still makes me pause and it was surprising to see how big the influence was.”

Lepak said strategies to limit the spread of COVID-19 likely had a “dramatic effect” on reducing respiratory virus activity and offered a “great opportunity” to significantly reduce antibiotic prescribing rates for respiratory viruses.

He added that the results underscore the need for “more comprehensive respiratory virus testing that is accessible and timely” in outpatient care settings.

“If providers and patients know what they have and can confirm it is a respiratory virus, it may be much more likely that both provider and patient are more comfortable with symptomatic therapy and avoidance of antibiotic prescriptions,” said he.


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Hana Akselrod, MD, MPH)

Hana Akselrod, MD, MPH

Although this interesting paper by Lepak and colleagues has the usual limitations of EHR-based studies, its results appear to be representative of the patterns observed in clinical practice and epidemiological studies over the past year.

The Lepak study goes even further, examining patterns of antibiotic prescribing within the same health system and finding a significant decrease in prescriptions for respiratory diseases, but not for other causes. This novel finding also makes sense in terms of what we see in clinical practice. Although the design of the study did not take into account individual patient outcomes (e.g., if a patient who was not originally prescribed antibiotics for respiratory infections later needed them), overall it was found that antibiotic prescriptions for respiratory infections in non-hospitalized patients increased by 79%. Patients have declined is very impressive.

This study highlights two long-standing public health problems: No. 1, the seasonal exposure to respiratory infections, and No. 2, the problem of overprescribing antibiotics for non-bacterial infections in the context of the COVID-19 pandemic. Masking and other non-pharmacological interventions for respiratory infections are highly effective when used consistently. The experiences of the past year should encourage us to keep these tools available and socially acceptable during the “cold and flu season” in order to reduce the annual burden of illness, absence from work and school among adolescents and mortality among the elderly and medically vulnerable .

Prior to the COVID-19 pandemic, the CDC and WHO viewed antibiotic resistance as one of the greatest public health challenges of our time, and there were concerns that the pandemic is exacerbating some of the trends that are driving antibiotic resistance, including the frequent use of Spectrum antibiotics in patients with severe COVID-19 and reduced constancy of non-COVID isolation precautions due to stress on personal protective equipment.

More studies are needed on how the pandemic has affected antibiotic resistance, what measures are effective to contain it, and how this differs from outpatient settings in hospitals. It would also be important to examine the relative role of prescribing behavior (e.g. tendency to prescribe antibiotics) versus patient preference and care behavior (e.g. threshold to visit a doctor) and how office closures and telemedicine have contributed could this. It would also be interesting to see if there are differences in respiratory infections and antibiotic prescribing patterns between states based on which pandemic restrictions were implemented and when.


CDC. Antibiotic / antimicrobial resistance. Available at: Accessed June 21, 2021.

Olsen SJ et al. MMWR Morbid Mortal Weekly Rep. 2020; doi: 10.15585.mmwr.mm6937a6.

Peek K. The scientific American. The flu disappeared worldwide during the COVID-19 pandemic. Available at: Accessed June 21, 2021.

Rodríguez-Baño J, et al. Trans R Soc Trop Med Hyg. 2021; doi: 10.1093 / trstmh / trab048.

Hana Akselrod, MD, MPH

Assistant Professor and Doctor, Infectious Diseases Department

The George Washington University School of Medicine and Health Sciences

Disclosure: Akselrod does not report any relevant financial information.


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