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Dear Editor,
We have read with keen interest the article by Rousselot et al. on the changes in ambulatory antibiotic use in France during the COVID-19 pandemic (1). We are writing from our perspective as a family medicine researchers based in Spain. The findings of Rousselot and colleagues regarding the sustained decrease in the use of most antibiotics, the peculiar exception of azithromycin, and the potential role of altered health care access are thought provoking, especially for those who work in settings similar to French primary care.
Their analysis resonates with the well-documented problem of antibiotic overuse in many European countries, including Spain. Spain, like France, has historically faced high rates of antibiotic consumption, which is often associated with increased antimicrobial resistance (2). The observation by Rousselot et al. that pandemic-related restrictions, reduced clinic visits, and diminished circulation of non–COVID-19 respiratory viruses may have contributed to a persistent drop in antibiotic dispensing is a crucial element in current discussions on appropriate antibiotic use. As reported in prior large-scale studies, reductions in prescriptions can sometimes be attributed to improved prescribing practices, but they may also reflect limitations in health care access (3). Distinguishing between these two scenarios is essential. If lower antibiotic usage stems from genuine improvements in evidence-based stewardship, it would portend a genuine step forward in addressing the global threat of resistance. However, if it is merely a side effect of patients being unable or unwilling to seek in-person evaluations, it raises the possibility of delayed or suboptimal treatment for bacterial infections and emphasizes the need for strategies to ensure equal access to care in critical situations.
From our vantage point in Spain, we witnessed similar patterns during the pandemic. Many patients were hesitant to visit primary care centers for fear of contracting the coronavirus, and the lockdown measures imposed by the government restricted patient flow in clinics, especially in the first months of the pandemic. As Rousselot et al. also point out, this phenomenon can sometimes lead to an underdiagnosis or delayed diagnosis of bacterial infections. We perceive, however, an upside in the context of antibiotic overprescription, a longstanding problem in outpatient settings. Before COVID-19, there was extensive evidence suggesting that numerous upper respiratory tract infections and mild urinary tract infections were often unnecessarily treated with antibiotics (4). In that sense, the lockdown period acted as an involuntary experiment, exposing the extent to which a subset of antibiotic prescriptions may have been avoidable. This observation should not overshadow the simultaneous concern that fewer direct consultations might have led, in some instances, to inadequate or late prescriptions for those truly requiring them. Determining the balance between these two factors remains an important public health question.
One particular aspect that Rousselot et al. highlight is the use of azithromycin during the first year of the pandemic. From the Spanish primary care viewpoint, azithromycin prescriptions also appeared to remain steady or even increase for a period, likely reflecting the initial wave of misinformation that circulated during the early stages of COVID-19 (1). It was prematurely hypothesized as a potential therapy for SARS-CoV-2, which created a surge in public demand. Such misconceptions underscore the role family physicians must adopt: we are often the first line of credible information for our communities, and we are uniquely positioned to dispel unproven claims (5). There is substantial literature emphasizing the dangers of misinformed prescribing, especially in the context of antibiotic resistance (6). This scenario was a reminder that quick dissemination of unverified treatment claims, even if well intentioned, can undermine antibiotic stewardship efforts.
Beyond misinformation, Rousselot et al.’s findings also shed light on how pandemic logistics shaped antibiotic distribution. The authors note that certain medications used for chronic conditions showed early increased dispensing, suggesting precautionary stockpiling by patients with underlying comorbidities (1). We observed a parallel in Spain, not limited to antibiotics but also including medications for cardiovascular diseases and diabetes. In rural primary care centers especially, many older adults chose to build a personal reserve of maintenance medications. Although such behavior may be understandable amid uncertainty, it highlights how prescribing patterns can be driven more by fear and limited mobility than by clinical indications. This raises questions about the role of teleconsultations or electronic prescribing. When appropriately implemented, remote consultation can maintain continuity of care and relieve pressure on overburdened clinics, but it can also introduce doubts for physicians who do not have direct physical examination data. In some cases, such doubts might lead to conservative decisions, like prescribing an antibiotic “just in case.” The relationship between telemedicine and antibiotic prescriptions in Spain has not yet been completely clarified, although preliminary data suggest that virtual consultations can be a double-edged sword, potentially reducing face-to-face visits where prescribing is often requested, yet sometimes increasing diagnostic uncertainty (2).
In this context, we concur with Rousselot et al. about the paramount role of family physicians in sustaining robust antibiotic stewardship (5). There is wide consensus in the European healthcare community, supported by global action plans, that primary care clinicians hold a fundamental position in improving antibiotic usage (2,3). Optimization programs, which include peer reviews, prescription audits, and continuing education, have proven beneficial in lowering unnecessary prescriptions in numerous settings. As family physicians in Spain, we routinely rely on such initiatives, guided by national strategies, to reinforce judicious prescribing for respiratory tract infections in particular. These efforts align with findings from Rousselot et al. that reflect a potential overprescription of antibiotics for infections that were perhaps predominantly viral. The pandemic context might have unexpectedly proved that a significant portion of antibiotic prescriptions were avoidable and were heavily influenced by frequent patient visits, in-person demands for medication, and strong social expectations.
However, limited access to care can pave the way for another problem in antibiotic stewardship: unregulated use or self-medication, especially if patients feel they must treat themselves at home with leftover drugs. In Spain, although the sale of antibiotics without prescription is illegal, anecdotal evidence suggests that some patients, particularly in the early phases of the pandemic, turned to leftover antibiotics or unverified online sources to treat mild symptoms. Such actions are worrisome and compromise effective stewardship measures, since the volume of non-reimbursed or informal antibiotic usage often remains unaccounted for. We commend Rousselot et al. for emphasizing the need to interpret their time-series results with care, given the possibility that a fraction of the population might have used antibiotics outside the regulated system.
The pandemic has, therefore, offered a window of opportunity for rethinking antibiotic stewardship in primary care. Major public health organizations worldwide, including the World Health Organization, have repeatedly stressed the urgent nature of antimicrobial resistance (2). As Rousselot et al. suggest, the substantial fall in the use of certain antibiotics, alongside only a moderate rise in azithromycin, indicates that targeted education regarding the actual role of antibiotics in viral conditions could be effective in the long run. The challenge lies in consolidating these beneficial changes—particularly the lower rate of prescribing for likely viral infections—and preventing complacency as the pandemic recedes.
Public awareness campaigns remain a key factor in supporting these objectives (5,7). While antibiotic stewardship interventions have primarily focused on prescribers, large-scale awareness initiatives aimed at the general public may bolster these efforts. The pandemic revealed that broader behavioral changes, such as handwashing, mask use, and physical distancing, had an impact on the overall spread of infectious diseases. These lessons could be extended to antibiotic use campaigns, highlighting the role of non-pharmacological measures in reducing transmission and pointing out when antibiotics are genuinely needed. Empirical evaluations of such measures have shown that multi-tiered public engagement strategies can sustain meaningful reductions in unnecessary prescribing (4).
In our opinion, the work of Rousselot et al. contributes valuable data on the multifaceted changes in antibiotic use triggered by the pandemic (1). From our vantage point in Spanish primary care and independent research, their findings raise several lines of reflection regarding physician prescribing habits, the risks of misinformation related to antibiotics, the balance between accessibility and correct diagnosis, and the possibility of leveraging this unique period to reinforce sensible antibiotic practices. The initial drop in antibiotic use that was driven by restricted health care access must not mask more encouraging shifts in prescriber behavior and patient awareness. Our collective challenge as family physicians is to build on these experiences so that post-pandemic antibiotic prescribing reflects the clinical realities of bacterial infection rather than habits shaped by patient demand, fear, or logistical barriers. We believe that further research comparing data from different European countries would be valuable in clarifying how these insights translate across diverse settings and cultures. Meanwhile, we hope that stewardship initiatives capitalizing on the pandemic’s lessons will be able to help reduce the global burden of antimicrobial resistance, an effort that is unlikely to succeed without continuous commitment from both prescribers and the public at large.
REFERENCES:
1. Rousselot N, Brayan T, Dumartin C, Clément M, Pariente A. Changes in the Ambulatory Use of Antibiotics in France Due to the COVID-19 Pandemic in 2020-2022: A Nationwide Time-Series Analysis. Ann Fam Med. 2025 Mar 1;23(2):158–61.
2. World Health Organization. Global action plan on antimicrobial resistance [Internet]. WHO Library Cataloguing-in-Publication Data; 2015. Available from: https://www.who.int/publications/i/item/9789241509763
3. Goossens H, Ferech M, Stichele RV, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet. 2005 Feb 12;365(9459):579–87.
4. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010 May 18;340:c2096.
5. Tenajas R, Miraut D. From Prescription to Prevention: How Patient Education Can Curb Antibiotic Misuse. Ann Fam Med. 2024 Sep 30;22(5):eLetter.
6. Olesen SW, Barnett ML, MacFadden DR, Brownstein JS, Hernández-Díaz S, Lipsitch M, et al. The distribution of antibiotic use and its association with antibiotic resistance. Ferguson NM, Jha P, editors. eLife. 2018 Dec 18;7:e39435.
7. Tenajas R, Miraut D. Unhurried Conversations in a Hurried System: Lessons from Spanish Primary Care. Ann Fam Med. 2025 Jan 19;23(1):eLetter.