Research examines antibiotic use during COVID-19 by age

In a research letter published in JAMA Health Forum, researchers evaluated antibiotic prescriptions during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-associated health visits in outpatient settings by United States (US) residents aged ≤64 years who have commercial health insurance.

The coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented morbidity and mortality across the globe. A considerable proportion of outpatient SARS-CoV-2 infection-associated visits among Medicare-insured individuals result in antibiotic prescribing. Analyzing COVID-19-associated antibiotic prescribing could inform antibiotic stewardship policies and programs.

Research Letter: Antibiotic Receipt During Outpatient Visits for COVID-19 in the US, From 2020 to 2022. Image Credit: solarseven / Shutterstock

About the research letter

In the present research letter, researchers reported findings of a study on antibiotic prescribing to COVID-19 outpatients residing in the United States between 2020 and 2022.

The cross-sectional study was conducted to assess trends in antibiotic prescribing to COVID-19 outpatients with the U07.1 international statistical classification of diseases and related health problems, tenth revision (ICD-10) code, between 1 April 2020 and 31 May 2022. The study comprised pediatric individuals aged ≤17.0 years and adult individuals aged between 18 years and 64 years, identified from the OptumLabs data warehouse, comprising de-identified health claims data of 10.0 percent to 20.0 percent of US residents with health insurance.

Pharmaceutically and medically-covered individuals visiting outpatient departments were identified, and the relationship of the individuals with antimicrobial prescriptions within one week prior to or post-visits was evaluated. The analysis was restricted to outpatient visits associated with SARS-CoV-2 infections, and five percent of the visits and their associated antibiotic prescriptions were excluded for individuals with co-diagnoses requiring antibiotics.


The study comprised 177,057 and 1,293,303 pediatric and adult COVID-19 outpatients, respectively. Antibiotic prescribing rates during SARS-CoV-2 infection-associated visits were more significant among older individuals, four percent among individuals aged ≤5.0 years and 16.0% among those aged between 45 and 64 years.

Twenty percent and seven percent of health visits and antibiotic prescribing for acute respiratory tract infection were among COVID-19 patients across ages. In the sensitivity analysis, antibiotic prescribing within two (versus seven) days of outpatient visits was four percent versus five percent among pediatric individuals and 11.0% versus 13.0% among adults.

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SARS-CoV-2 infection-associated outpatient consultations among pediatric individuals versus adult individuals took place mainly at physicians’ offices (66.0% versus 51.0%), emergency departments (12.0% versus 18.0%), and telemedicine practices (11.0% versus 17.0%). Antibiotic prescription rates varied by the care site, with elevated rates during telemedicine practice visits and emergency department visits across ages, except for individuals aged ≤5.0 years.

Among pediatric individuals aged ≤5.0 years, antibiotic prescribing rates were the greatest for non-third-party telemedicine consultations between doctors and patients. Antibiotic prescribing rates in the US’s southern, western, mid-western, and north-eastern regions were 15.0%, 9.0%, 9.0%, and 7.0%, respectively. Among children aged <6.0 years, azithromycin and amoxicillin were the most frequently prescribed antibiotics. Among six- to 17-year-olds and among adult individuals, healthcare professionals prescribed the azithromycin antibiotic (68.0% and 70.0%) more frequently compared to the amoxicillin antibiotic (15.0% and four percent).


Based on the findings, antibiotic prescribing among COVID-19 outpatients was considerably lower among pediatric individuals than adults, with rates varying by care sites and the US regions. Elevated antibiotic prescribing rates among adults might be related to greater comorbidity prevalence and might enhance the risk of adverse COVID-19 outcomes.

Among adults and six- to 17-year-olds, antibiotics were prescribed most commonly at emergency departments and telemedicine practices, and azithromycin was most commonly prescribed, in accordance with prior reports. Healthcare professionals may prescribe azithromycin due to its probable antiviral and anti-inflammatory properties. However, Amoxicillin usage among the least-aged individuals raises concerns over associated bacterial-type infections such as pneumonia and otitis media.

Study limitations

The study has a few limitations, including inadequate data on Medicaid-insured health visits and health encounters by non-insured individuals and data retrieval during times of lower-than-usual pediatric health visits and antibiotic usage for non-SARS-CoV-2 infection-associated ARTI. Moreover, the U07.1 code seems to have high specificity but lower sensitivity in identifying health outpatient visits associated with SARS-CoV-2 infections.

Health claims data were not inclusive of antibiotics prescribed but not purchased without health insurance. Furthermore, the relationship between comorbidities and COVID-19 severity with antibiotic usage was not assessed. Further research on antibiotic prescribing practices during successive waves of COVID-19 could aid in curtailing unnecessary antibiotic use and prevent the development of associated co-infections and antimicrobial resistance.

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