Prevalence of antibiotic prescribing in COVID-19 patients in China and other low- and middle-income countries during the pandemic (December 2019-March 2021): a systematic review and meta-analysis.

OBJECTIVES: Low- and middle-income countries (LMICs) are particularly vulnerable to the threat of antimicrobial resistance (AMR). Use of antibiotics to treat COVID-19 patients during the pandemic may have contributed to increasing the AMR burden, but systematic evidence is lacking. METHODS: We searched Web of Science, EMBASE, PubMed, China National Knowledge Infrastructure (CNKI) and VIP databases from 1 December 2019 to 31 March 2021. Interventional and observation studies across all settings that reported antibiotic use in at least 10 COVID-19 patients were included. We restricted publications to English and Chinese languages. Screening and data extraction were undertaken by at least two independent reviewers. Results were synthesized using random-effects meta-analyses. Subgroup analyses and meta-regression were used to explore heterogeneities. This review was registered with PROSPERO (CRD42021288291). RESULTS: We included 284 studies involving 210 611 participants in 19 countries. The antibiotic prescribing rates (APRs) in COVID-19 inpatients were 71.7% (95% CI 66.7%-76.5%) in China and 86.5% (77.1%-93.9%) in other LMICs, respectively. APR was lower in mild/moderate cases in China [66.9% (57.9%-75.4%) compared with 91.8% (71.4%-100%) in other LMICs]. High APRs were found among pregnant women and the elderly in China. Disparities in APRs of other patient groups were identified. In studies reporting bacterial infections, the prevalence was 17.3% (10.0%-25.9%) in China and 24.9% (0.1%-68.8%) in other LMICs. Several antibiotics on the WHO 'Watch' and 'Reserve' lists were prescribed frequently in LMICs. CONCLUSIONS: Inappropriate antibiotic use and high prevalence of antibiotic prescribing were found in COVID-19 inpatients in many LMICs.

Antibiotic Use and Bacterial Infection in COVID-19 Patients in the Second Phase of the SARS-CoV-2 Pandemic: A Scoping Review.

This scoping review aimed to explore the prevalence and patterns of global antibiotic use and bacterial infection in COVID-19 patients from studies published between June 2020 and March 2021. This review was reported in line with the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews, and the protocol is registered with the Open Science Framework. Compared with our previously-published review of the period (December 2019-June 2020), the antibiotic prescribing rate for COVID-19 patients (June 2020-March 2021) was found to have declined overall (82.3% vs. 39.7%), for mild and moderate patients (75.1% vs. 15.5%), and for severe and critical patients (75.3% vs. 48.3%). The seven most frequently prescribed antibiotics in COVID-19 patients were all on the "Watch" list of the WHO AWaRe antibiotics classification. The overall reported bacterial infection rate in COVID-19 patients was 10.5%, and the most frequently reported resistant pathogen in COVID-19 patients was Staphylococcus aureus, followed by Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae. There is an urgent need to establish comprehensive and consistent guidelines to assist clinicians in selecting appropriate antibiotics for COVID-19 patients when needed. The resistance data on the most frequently used antibiotics for COVID-19 patients for certain resistant pathogens should be closely monitored.