Original research in the older age group. This decrease is despite many stewardship programmes in the UK being negatively impacted due to COVID- 19, suggesting clinicians are effectively following guidelines to use Access antibiotics as first-line options. Work conducted in England indicated that the rate of patients prescribed Watch anti- biotics rose, particularly early in the pandemic. 14 In contrast, our results showed decreasing rates of Watch prescribing, indicating responsiveness from clinicians to rapidly developed guidelines. These results showing lower use of broader spectrum agents may suggest the positive impact of efforts by local and national groups such as the Scottish Antimicrobial Prescribing Group (SAPG) in Scotland continuing to promote appropriate antibiotic use during the COVID-19 pandemic, and this could be a reason for apparent differences with England and Wales. 15 This does not rule out a spike in use over shorter time periods around the first lockdown but is nonetheless reassuring. Where other studies found increased antibiotic prescribing in older age groups, 5 longer term trends here showed this age group had the largest reductions in higher risk antibiotic categories. However, over half of antibiotic prescriptions were in the older age group, therefore this remains a key patient cohort to target interventions towards. Given the increased risk of recurrent and resistant infections in this age group, who are more likely to be exposed to repeated courses of antibiotics and hospital admis- sions, 16 this is a positive trend. Despite assumptions that overlapping respiratory symptoms of COVID-19 and bacterial pneumonia may cause overprescribing and unnecessary escalation, it is reassuring that this was not borne out in our results, possibly due to effective early messaging from infection prevention and control teams, and dissemination of early research showing infrequent concomitant bacterial and COVID-19 infections. 17 Ultimately, it seems that the impact of COVID-19 on the util- isation and quality of antibiotic usage in Scotland appears to be non-detrimental. This observation can likely be attributed to the effective implementation of antimicrobial stewardship initia- tives championed by the SAPG. 18 SAPG has been proactive on a national scale, promoting practices such as antibiotic reviews, the reduction of prescription durations when appropriate and cessa- tion of antibiotic use on confirmation of COVID-19. 10 12 18 19 Furthermore, SAPG has developed specific prescribing guidelines for both primary and secondary care. In tandem with these efforts, a communication from the Scottish government addressed to all prescribers, including the chief medical officer, chief pharmacy officer and chief nursing officer, aimed to encourage judicious anti- biotic prescribing during the pandemic. The strength of this study is the currency and detail of the data available. The main limitation is incomplete geograph- ical coverage and lack of information on the indication for the prescribed antibiotics. Furthermore, results portray the picture in Scottish hospitals only. Acknowledgements We thank all lead COVID-19 and HEPMA pharmacists from NHS Health Boards in Scotland for their assistance in collecting the data presented here. Contributors Writing and literature search were conducted by EP. TM, KG and AM conducted data analysis. All authors contributed to data interpretation and approved the final manuscript. WM and MB conceived and oversaw this work. EP is the guarantor of this work. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Competing interests None declared. Patient consent for publication Not applicable.
Ethics approval Ethics approval was not deemed necessary due to the nature of the study. This was a retrospective medication utilisation study with anonymised findings at a population level. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data can be available via Public Health Scotland’s electronic Data Research and Innovation Service, subject to reasonable request and public benefit and privacy panel evaluation. Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. ORCID iD Euan Proud http://orcid.org/0000-0002-6014-9881 REFERENCES 1 Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis - the lancet. Available: https://www. thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext [Accessed 5 Dec 2022]. 2 World Health Organisation. WHO antibiotics portal. Available: https://aware. essentialmeds.org/groups [Accessed 5 Dec 2022]. 3 Budd E, Cramp E, Sharland M, et al . Adaptation of the WHO essential medicines list for national antibiotic stewardship policy in England: being AWaRe. 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Available: https://www.gov.uk/government/publications/uk-5-year-action- plan-for-antimicrobial-resistance-2019-to-2024 [Accessed 14 Dec 2022]. 9 Group BMJP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007;335. 10 ARHAI Scotland. Scottish one health antimicrobial use and antimicrobial resistance in 2021. Scotland 2021. 2021. Available: https://www.nss.nhs.scot/publications/scottish- one-health-antimicrobial-use-and-antimicrobial-resistance-in-2021/ [Accessed 6 Dec 2022]. 11 Seaton RA, Cooper L, Gibbons CL, et al . Antibiotic prescribing for respiratory tract infection in patients with suspected and proven COVID-19: results from an antibiotic point prevalence survey in Scottish hospitals. JAC Antimicrob Resist 2021;3:dlab078. 12 Russell CD, Fairfield CJ, Drake TM, et al . Co-infections, secondary infections, and antimicrobial use in patients hospitalised with COVID-19 during the first pandemic wave from the ISARIC WHO CCP-UK study: a multicentre, prospective cohort study. Lancet Microbe 2021;2:e354–65. 13 Khan S, Hasan SS, Bond SE, et al . Antimicrobial consumption in patients with COVID-19: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2022;20:749–72. 14 Andrews A, Budd E, Hendrick A, et al . Surveillance of Antibacterial Usage during the COVID-19 Pandemic in England, 2020. Antibiotics 2020;10:841. 15 Seaton A. COVID-19 and its impact on antimicrobial stewardship. REVIVE. Available: https://revive.gardp.org/covid-19-and-its-impact-on-antimicrobial-stewardship/ [Accessed Nov 2023]. 16 Faulkner CM, Cox HL, Williamson JC. Unique aspects of antimicrobial use in older adults. Clin Infect Dis 2005;40:997–1004. 17 Alshaikh FS, Godman B, Sindi ON, et al . Prevalence of bacterial coinfection and patterns of antibiotics prescribing in patients with COVID-19: A systematic review and meta-analysis. PLOS ONE 2022;17:e0272375. 18 MacBride-Stewart S, McTaggart S, Kurdi A, et al . Initiatives and reforms across Scotland in recent years to improve prescribing; findings and global implications of drug prescriptions. Int J Clin Exp Med 2021;14:2563–86. 19 Seaton RA, Gibbons CL, Cooper L, et al . Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals. J Infect 2020;81:952–60.
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