Analysis of the use of antibiotics by AWaRe categories during the COVID-19 pandemic in hospitals across Scotland : a national population-based study

Proud, Euan and Mueller, Tanja and Gronkowski, Karen and Kurdi, Amanj and Platt, Niketa and Morrison, Aidan and Bennie, Marion and Malcolm, William (2024) Analysis of the use of antibiotics by AWaRe categories during the COVID-19 pandemic in hospitals across Scotland : a national population-based study. European Journal of Hospital Pharmacy. 003874. ISSN 2047-9956 (

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Objective: The Access, Watch and Reserve (AWaRe) list of antibiotics has been developed by the World Health Organisation (WHO) to support antibiotic stewardship programs (ASP). The Access group incorporates first-line options, while Watch antibiotics generally have higher potential for resistance or toxicity, and Reserve drugs should be used only for complex infections. Nevertheless, ASP implementation has been challenged during the COVID-19 pandemic. There is a knowledge gap regarding in-hospital prescribing patterns of antibiotics nationally during the COVID-19 pandemic, as well as data on the characteristics of hospitalised patients being prescribed antibiotics during this time. Therefore, we aimed to evaluate quality of antibiotic use according to the AWaRe classification in Scottish hospitals, including assessing the potential impact of COVID-19 on prescribing trends. Methods: Cross-sectional study of antibiotics prescribed to hospitalised patients from 1st January 2019 to 30th June 2022 in a selection of Scottish hospitals, covering approx. 60% (3.6M people) of the Scottish population. Data was obtained from the Hospital Electronic Prescribing and Medicines Administration system. Prescribing trends were explored over time, by age group and by sex. Results: Overall, a total of 1,353,003 prescriptions were identified. An increase in Access antibiotics use was found from 55.3% (31901/57708) to 62.3% (106449/170995) over the study period, alongside a decrease in Watch antibiotics from 42.9% (24772/57708) to 35.4% (60632/170995). Reserve antibiotic use was limited throughout, with only minor changes observed over time. Changes in prescribing were most pronounced in the older age group (>65 years): proportions of Access antibiotics increased from 56.4% (19353/34337) to 65.8% (64387/97815, p<0.05), while Watch antibiotics proportions decreased from 41.9% (14376/34337) to 32.3% (31568/97815, p<0.05) between Q1 2019 and Q2 2022. Differences between male and female patients were insignificant. Conclusions: Findings showed encouraging trends in Access and Watch class use among hospitalised patients, in line with Scottish national standards. There was no noteworthy effect of COVID-19 on prescribing trends despite reports indicating many stewardship programs being negatively impacted by the pandemic.