A marked reduction in pediatric outpatient antibiotic prescribing was observed in Portugal during the COVID-19 pandemic, especially for Amoxicillin (with and without β-lactamase inhibitor) and macrolides, antibiotics mostly used in the management of respiratory-tract infections.
The observed reduction has been sustained for 12 months, but was much more pronounced during the two COVID-19 waves and respective lockdown periods, from March to the beginning of May/2020 and from November/2020 to February/2021. These results may be explained, at least partially, by the confinement and non-medical interventions adopted such as physical distancing, widespread use of masks, hygiene measures and closure of schools, resulting in lower incidence of some infections, in particular those of the respiratory tract.
An observation that also supports this explanation is the much greater reduction seen in younger children, particularly in pre-school age, a group with higher incidence of respiratory-tract infections. This represents a clear shift - before the pandemic, consumption was much higher in under 10’s than in teenagers, while during the pandemic these values were similar, due to a much smaller reduction in teenagers.
The wish to avoid using limited resources, the fear of contracting COVID-19 by going to health care centers and the fact that COVID-19 in children is usually a mild self-limiting infection may also have contributed to parents adopting a ‘watch and wait’ approach instead of seeking medical care. This may also have contributed to lower prescription rates.
On the other hand, antibiotics which are more commonly used to treat urinary tract infections (Co-Trimoxazole and Fosfomycin) had much less pronounced reductions. These infections generally do not result from human to human transmission and therefore should be less affected by the above mentioned non-medical interventions.
Despite the differences in the background rates of prescription, similar proportionate reductions in antibiotic use were observed in all regions of the country, suggesting a consistency in physicians’ behavior in the context of falling numbers of presentations with acute infections.
While some similar findings have been reported in recent studies from Scotland6, England7 and the Netherlands8, that also found a reduction in both incidence of infectious diseases and antibiotic consumption in the general population, particularly in respiratory-tract infections and prescription of penicillins, our study, limited to children and adolescents, adds more detail about different pediatric age groups and covers a longer period of time that spans 2 lockdowns and intervening non-lockdown period during the pandemic. It evaluates data on ambulatory prescribing by GPs and hospital emergency services in a country which, in contrast to those which have previously reported, is in the “middle band’ for usage of antibiotics, and shows comparable decreases to those seen in these “low-use” countries. [7–9]
The strengths of this study are its sample size, the use of national data from a robust electronic system and the comparison of these data between pre- and per-pandemic time periods.
However, there are limitations - the data relates to prescriptions issued and we had no access to information as to whether they were dispensed and taken, nor on indication for prescription.
Further investigation is needed to ascertain whether there was any increase in complications of acute infectious diseases as a consequence of not seeking healthcare advice although others have found no evidence of any such increase [7].
Further monitoring is necessary to see whether this reduction in community prescribing, a very high source of antibiotic use, persists and whether these changes will impact antimicrobial resistance. It will be interesting to observe the impact of the lessons learnt from this pandemic.
These observations advocate the importance of effective public health communication about non-medical interventions, not only in fighting the spread of SARS-CoV-2 but also of other infections and, additionally, for better and more rational use of health care services for some acute infections, with subsequent reductions in antibiotic prescribing.
In conclusion, our findings indicate that the COVID-19 pandemic has had a profound effect on antibiotic use in ambulatory care in children in Portugal.