Clinical Scorecard: Trends in Antibiotic Use Among Adults Hospitalized for COVID-19 and Other Viral Respiratory Infections

At a Glance

Key Highlights

• At pandemic onset, >80% of COVID-19 inpatients and nearly 70% of other viral ARTI inpatients received antibiotics.
• Antibiotic prescribing declined over time, stabilizing around 35% for COVID-19 and returning to ~50% for other viral ARTIs by 2023.
• Potentially unnecessary antibiotic use remains a critical target for antimicrobial stewardship in viral ARTIs.

Guideline-Based Recommendations

Diagnosis

• Use ICD-10 codes to identify symptomatic COVID-19 and non–COVID-19 viral ARTIs.
• Exclude cases where antibiotics are always or sometimes necessary to focus on potentially unnecessary prescribing.

Management

• Avoid routine antibiotic prescribing in viral ARTIs without evidence of bacterial coinfection.
• Implement antimicrobial stewardship programs to reduce unnecessary antibiotic use.

Monitoring & Follow-up

• Track antibiotic prescribing rates during the first 5 days of hospital admission for viral ARTIs.
• Monitor trends over time to assess stewardship program impact.

Risks

• Unnecessary antibiotics increase risk of antibiotic resistance, adverse drug events, and Clostridioides difficile infection.
• Antibiotic-induced gut dysbiosis may impair lung immune response and worsen viral ARTI severity.

Patient & Prescribing Data

513,698 COVID-19 and 106,932 non–COVID-19 viral ARTI adult admissions from 803 US hospitals (2019–2023)

High initial antibiotic use decreased over time but remains substantial; stewardship efforts needed to further reduce unnecessary prescribing.

Clinical Best Practices

• Apply tiered ICD-10 code frameworks to classify necessity of antibiotic prescribing.
• Exclude patients with diagnoses warranting antibiotics to focus stewardship on unnecessary use.
• Educate clinicians on low bacterial coinfection rates in viral ARTIs to reduce empirical antibiotic use.
• Strengthen antimicrobial stewardship programs disrupted during the COVID-19 pandemic.
• Use large hospital databases to monitor prescribing trends and guide interventions.

References

• Premier Healthcare Database
• CDC Antibiotic Resistance Threats in the United States, 2019
• Wattles et al. Tiered ICD-10 Antibiotic Prescribing Framework
• Garibaldi et al. Algorithm for Symptomatic COVID-19 Identification