Early antibiotic review and AWaRe prescribing in respiratory infections before vs during COVID-19: a two-hospital retrospective cohort study

Background: Antimicrobial resistance poses a critical global health threat, with antimicrobial stewardship (AMS) programmes essential for optimising antibiotic use. The COVID-19 pandemic disrupted healthcare systems worldwide, yet evidence on whether core stewardship activities, particularly early antibiotic review (defined as review at 48–72 hours, i.e. Day 2–3), were maintained during this period remains limited. This study evaluated antibiotic review practices and prescribing patterns in hospitalised patients with respiratory tract infections before and during the pandemic. Methods: A retrospective cohort study was conducted at two acute care hospitals within an NHS Foundation Trust in England. Adult patients (≥25 years) admitted with respiratory tract infections and prescribed systemic antibiotics were included from 2019 (pre-pandemic) and 2020 (pandemic). Data were extracted on antibiotic review timing, stewardship interventions (using the CARES framework), and prescribing patterns (using WHO AWaRe classification). Stratified systematic random sampling yielded 640 patients (320 per year, 160 per hospital per year). Results: The median patient age was 78 years in 2019 and 79 years in 2020, with similar mortality between periods (15.0% vs 15.6%, p=0.83). Early antibiotic review (Day 2–3) was maintained at approximately 51% during both periods (51.6% in 2019 vs 50.9% in 2020, p=0.87). However, Watch category antibiotic prescribing increased significantly from 52% in 2019 to 60% in 2020 (p<0.001), with corresponding reductions in Access antibiotic use. Reserve antibiotics remained appropriately restricted (3–5%). Among guideline-concordant prescriptions, de-escalation was the most frequent stewardship intervention (19–38%), while continuation without documented change increased during the pandemic (rising from 7% and 9% in 2019 to 21% and 16% in 2020 at Hospitals A and B, respectively). Conclusions: Early antibiotic review practices demonstrated resilience during the COVID-19 pandemic, enabling continued stewardship interventions despite operational pressures. However, the shift toward broader-spectrum prescribing highlights the need for enhanced diagnostic stewardship and pandemic-resilient AMS infrastructure. These findings suggest pharmacists may play an important role in supporting sustainable antimicrobial stewardship through embedded review processes and multidisciplinary collaboration, though direct causal attribution requires further investigation. Investing in workforce development and digital stewardship tools is essential for sustaining effective antibiotic optimisation during future health system disruptions.