Antibiotic prescribing in general practice during COVID-19 and beyond

Richard Armitage and Laura B Nellums¹ reported that when accounting for changes in appointment numbers, the total number of antibiotics prescribed between April 1, and Aug 31, 2020, was 6·71% higher than expected—a statistically significant increase.

By use of updated data, we were able to assess whether the increase was sustained throughout the pandemic and beyond. OpenPrescribing publishes monthly data for the number of items prescribed in general practice in England, UK. National Health Service (NHS) England provides monthly data for appointment activity in general practice.²

We conducted an interrupted time-series analysis using the negative binomial model and data from Jan 1, 2018, to July 31, 2022. Interruptions were set at the months of March, 2020, the start of the pandemic, and July, 2021, when restrictions were lifted in England, UK. All data and analysis code are available online.³

In accordance with Armitage and Nellums,¹ we identified that there was an immediate increase in the mean number of items prescribed per 100 appointments at the start of the COVID-19 pandemic (incidence rate ratio [IRR] 1·14, 95% CI 1·07–1·23). However, the prescribing rate gradually declined from May, 2020, onwards (IRR 0·98, 95% CI 0·97–0·98) and was lower than the expected trend from December, 2020, to July, 2021, coinciding with the third national lockdown, from Jan 5, 2021, to July 19, 2021 (appendix p 1). The lifting of lockdown restrictions in July, 2021, saw an immediate increase in the prescribing rate (IRR 1·21, 95% CI 1·11–1·33), which continued to gradually increase (1·03, 1·02–1·04) until it was in line with the expected trend.

Conversely, the start of the pandemic saw an immediate decrease in the absolute number of antibiotics prescribed (IRR 0·85, 95% CI 0·80–0·91), and the absolute number of antibiotics prescribed remained below the expected trend throughout the period of COVID-19 restrictions, from March, 2020, to July, 2021 (appendix p 1). The lifting of lockdown restrictions in July, 2021, saw an immediate increase in the number of items prescribed (IRR 1·18, 95% CI 1·09–1·29]).

Armitage and Nellums suggested that the increase in antibiotic prescribing was driven by the sharp increase in telephone appointments during the COVID-19 pandemic.¹ The proportion of general practice appointments conducted via telephone, although decreasing, remains high at 31·6% in July, 2022, compared with 14·2% in July, 2019 (appendix p 1). Nevertheless, antibiotic prescribing rates have returned to the expected trend of falling antibiotic consumption in general practice. Our data provide little population-level evidence of an association between telephone appointments and inappropriate antibiotic stewardship, because prescribing rates have continued to decrease despite a high proportion of general practice appointments being conducted via telephone.

Clinicians should still be supported to use antibiotics appropriately. However, when considering the impact of the total pandemic restrictions in England, UK, there is little evidence that COVID-19 has hindered attempts by the NHS to reduce antibiotic prescribing on the whole.⁴

KKCM reports grants from the CW Maplethorpe Fellowship, the UK National Institute for Health Research, the European Commission, AIR@InnoHK administered by Hong Kong Innovation and Technology Commission, and the Research Grant Council, Hong Kong; and reports personal fees from IQVIA, unrelated to this Correspondence. ICKW reports research funding outside the submitted work from Amgen, Bristol Myers Squibb, Pfizer, Janssen, Bayer, GSK, Novartis, the Hong Kong Research Grants Council, the Hong Kong Health and Medical Research Fund, the Hong Kong Innovation and Technology Commission, the UK National Institute for Health Research, the European Commission, and the National Health and Medical Research Council in Australia and received expert testimony payment from the Hong Kong Court of Final Appeal, consultation fees from IQVIA, and speaker fees from Janssen and Medice in the previous 3 years. ICKW is the principal investigator and KKCM is the co-investigator of the project for A Multinational Big Data COVID-19 Epidemiological Study on Post-infection Outcomes (ACESO), funded by the Hong Kong Research Grant Council Collaborative Research Fund Coronavirus Disease and Novel Infectious Diseases Research Exercise, to study the impact of COVID-19 on drug prescribing (grant number C7154–20GF). WCYL reports grant from AIR@InnoHK administered by the Innovation and Technology Commission, unrelated to this Correspondence. All other authors declare no competing interests.