Antibiotic prescribing practices during the COVID-19 pandemic: A post-hoc analysis of the Adaptive COVID-19 Treatment Trial

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ID: 324944
2026
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Abstract
Abstract Background The COVID-19 pandemic exacerbated antibiotic overuse; however, gaps remain regarding the timing of administration and whether prescribing is supported by evidence of bacterial infection. Methods Antibiotic use was described within the Adaptive COVID-19 Treatment Trial (ACTT), a series of randomized controlled therapeutics trials in adults hospitalized with COVID-19 from Feb 2020-May 2021. Proportions of participants receiving antibiotics by trial stage were described (overall, pre-randomization, post-randomization). Analyses were repeated for CDC’s National Healthcare Safety Network (NHSN) categories and for antibiotics used for community-acquired pneumonia (CAP) according to IDSA guidelines. In ACTT-2 and ACTT-4, lab culture results were documented for Grade 3 or greater infection adverse events; proportions of antibiotic recipients with a positive culture were compared between trials. Results Most (62%) of the 4,074 participants received at least one antibiotic. Pre-randomization antibiotic use declined across ACTT stages, from 72% in ACTT-1 to 32% in ACTT-4. The largest decrease noted is within the NHSN category for community-acquired infection (decreasing significantly from 49% in ACTT-1 to 24% in ACTT-4). Post-randomization use was lower and declined modestly, from 28% to 18%. The percentage of post-randomization antibiotic recipients with a positive bacterial culture was 18% in ACTT-2 and 18% in ACTT-4. Conclusions Antibiotic use decreased substantially over the first pandemic year, however in-hospital prescribing remained common despite limited microbiologic confirmation of infection. Stewardship efforts during future respiratory viral pandemics should focus on reducing empiric antibiotic use for CAP-like illness at presentation and on strengthening reassessment, diagnostic stewardship, and de-escalation of later in-hospital antibiotic therapy.
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openalex_W7202357585 Use this key to autocite in the manuscript while using SciMatic Manuscript Manager or Thesis Manager
Authors Catharine I. Paules, Kevin Rubenstein, Kay M. Tomashek, Tyler Bonnett, Nadine Rouphael, Zanthia Wiley, Varduhi Ghazaryan, Rekha R. Rapaka, Gail E. Potter
Journal Open forum infectious diseases
Year 2026
DOI
10.1093/ofid/ofag503
URL
https://doi.org/10.1093/ofid/ofag503
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