We found a sharp decrease in prescribed and dispensed antibiotics in Sweden for the year 2020 compared to 2019. Most of the decrease was attributable to a lower dispensing of antibiotic prescriptions from pharmacies for respiratory tract infections. Children aged 0–4 years had the biggest reduction with an almost 80% decrease in 2020. At the same time, we found no increase in the number of hospitalisations or specialist consultations due to complications possibly related to untreated upper or lower respiratory tract infections, skin and soft tissue infections, or urinary tract infections during the same time period.
A register-based UK study showed that antibiotic prescriptions declined along with a concomitant substantial decline in consultations for respiratory and urinary tract infections, which was most evident among those of younger ages [8]. The same was seen in a study in the US where the number of dispensed antibiotic prescriptions decreased by 39% in April 2020 and by 42% in May 2020 compared to the same months in 2017–2019 and was greatest among children ≤19 years [1]. These studies, however, did not evaluate the impact on outcome.
We did not see any increase in the number of hospitalisations or consultations for complicating severe infections in 2020. Instead, there was a decrease in the number of patients diagnosed with the studied complicating infections. In particular, the number of patients hospitalised or treated in specialised outpatient care for pneumonia decreased from around 50 per month during 2017–2019 per 100,000 to around 26 per 100,000 in 2020 (Fig. 4). The decrease was most prominent in the age group over 70 years. Similarly, a recent study using the Danish National Patient Registry also found a decrease in the incidence of pneumonia during the Covid-19 pandemic [9]. However, our data did not allow for such an analysis.
We believe that the recommendations put in place since March 2020 to mitigate the Covid-19 pandemic – namely to stay at home if you have symptoms, wash your hands, and maintain social distancing – most likely had an impact on the transmission of common infections, and thus fewer doctors’ consultations and dispensed prescriptions. For example, reported cases of seasonal influenza [10], respiratory syncytial virus [11], and norovirus [12] were all significantly fewer in 2019/2020 than in earlier years. A general reduction in opportunities for transmission is supported by the fact that the total number of days disbursed to parents staying at home caring for their sick children (rather than sending them to school with mild symtoms) increased in Sweden by 24% in 2020 compared to the previous year (Supplementary Fig. S6) [13]. Furthermore, movement data from mobile phone companies have shown that people have stayed at home more than usual, thereby reducing the number of contacts with others [14]. Before the pandemic, there was a higher transmission of respiratory viruses in the community and more people visited primary care for RTI, and probably received antibiotics inappropriately.
In accordance with this, national Swedish data on physical visits to primary care demonstrated a total decrease of 31% for the first months of the pandemic [4], and data from the Stockholm region showed a 25% decline in visits compared to the previous three years (remote consultations included) [Thomas Loogna, Controller, Region Stockholm, personal communication, May 2021]. A systematic review [3] showed that there was an overall decrease of 37% in visits to health care during the first months of the pandemic. However, another study performed in the UK found that the number of remote consultations increased from April onwards and that the total number of consultations almost normalised towards the end of 2020, while the prescriptions of antibiotics remained low [15]. In a UK study, the number of face-to-face appointments decreased in April to August of 2020 compared to the same period in 2019, while telephone appointments increased by 20.8%. This resulted in a 15.5% reduction in prescriptions, but a higher prescription rate given the number of consultations [2]. A proposed explanation for the decline in prescriptions is the combination of an increase in remote consultations and a previously high rate of inappropriate antibiotic treatment for Covid-19 during physical consultations. Our analysis included antibiotic prescriptions issued during remote consultations. Unfortunately, we could not identify how large this proportion was or how it has changed over time.
This was a population-based study where we used the national patient register to identify hospitalisations and consultations. The coverage and quality of the diagnoses in the register are high and have been validated elsewhere [16]. The Swedish prescribed drug register is unique in that it covers the entire population and measures the dispensing of prescribed drugs at an individual level (not just the number of prescriptions). Hence, we believe that our data are quite complete. The major limitation of this study is that we were unable to link consultations for respiratory and urinary tract infections and exposure to antibiotics or not with later outcomes of complicating severe infection on an individual basis. Thus, it was not possible to assess if the observed decline in complications was appropriate in relation to the decline in consultations and dispensed prescriptions. Nevertheless, this was not the objective of the study, which was to detect if an increase in complications could be seen due to the decline in dispensed prescriptions.