antibiotics Review Antimicrobial Use in COVID-19 Patients in the First Phase of the SARS-CoV-2 Pandemic: A Scoping Review Wenjuan Cong 1, * , Ak Narayan Poudel 2 , Nour Alhusein 1 , Hexing Wang 3 , Guiqing Yao 2 and Helen Lambert 1   Citation: Cong, W.; Poudel, A.N.; Alhusein, N.; Wang, H.; Yao, G.; Lambert, H. Antimicrobial Use in COVID-19 Patients in the First Phase of the SARS-CoV-2 Pandemic: A Scoping Review. Antibiotics 2021, 10, 745. https://doi.org/10.3390/ antibiotics10060745 Academic Editors: Adolfo Figueiras and Mehran Monchi Received: 9 April 2021 Accepted: 15 June 2021 Published: 19 June 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK; nour.alhusein@bristol.ac.uk (N.A.); h.lambert@bristol.ac.uk (H.L.) 2 Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK; anp13@leicester.ac.uk (A.N.P.); gy38@leicester.ac.uk (G.Y.) 3 Key Laboratory of Public Health Safety of Ministry of Education, School of Public Health, Fudan University, Shanghai 200032, China; wanghexing@fudan.edu.cn * Correspondence: wenjuan.cong@bristol.ac.uk; Tel.: +44-0117-3314528 Abstract: This scoping review provides new evidence on the prevalence and patterns of global antimicrobial use in the treatment of COVID-19 patients; identifies the most commonly used antibi- otics and clinical scenarios associated with antibiotic prescribing in the first phase of the pandemic; and explores the impact of documented antibiotic prescribing on treatment outcomes in COVID-19 patients. The review complies with PRISMA guidelines for Scoping Reviews and the protocol is registered with the Open Science Framework. In the first six months of the pandemic, there was a similar mean antibiotic prescribing rate between patients with severe or critical illness (75.4%) and patients with mild or moderate illness (75.1%). The proportion of patients prescribed antibiotics without clinical justification was 51.5% vs. 41.9% for patients with mild or moderate illness and those with severe or critical illness. Comparison of patients who were provided antibiotics with a clinical justification with those who were given antibiotics without clinical justification showed lower mortality rates (9.5% vs. 13.1%), higher discharge rates (80.9% vs. 69.3%), and shorter length of hospital stay (9.3 days vs. 12.2 days). In the first 6 months of the pandemic, antibiotics were prescribed for COVID-19 patients regardless of severity of illness. A large proportion of antibiotic prescribing for mild and moderate COVID-19 patients did not have clinical evidence of a bacterial co-infection. Antibiotics may not be beneficial to COVID-19 patients without clinical evidence of a bacterial co-infection. Keywords: COVID-19 patients; disease severity; antibiotic use; clinical justification; secondary infections 1. Introduction Antimicrobial resistance (AMR) kills an estimated 700,000 people every year [1]. Without intervention, the current trajectory predicts a gloomy figure of 10 million fatalities by 2050 [2]. The SARS-CoV-2 pandemic foreshadows the crisis of living with an infectious disease for which there is no treatment and the damaging consequences to our health systems and economies. At the beginning of the pandemic, with the panic of facing the unknown, many existing medicines were repurposed to treat the virus. This included widespread use of antibiotics in treatment [3–7]. For example, in a multi-hospital cohort study in the USA, 56.6% of 1705 patients were prescribed early empiric antibacterial therapy, of which only 3.5% were confirmed to have bacterial infection [5]. Two systematic reviews found that, of the patients reported in the included studies, 72.0% received antibiotics, and 14.3% suffered a secondary bacterial infection [4,7]. The low proportion of COVID-19 patients having co-infection or secondary infection in these studies is consistent with other findings. For example, in Italy, from the 16,654 patients who died of COVID-19, only 11% were reported to have a secondary bacterial infection (data as of 9 April 2020) [8]. In Antibiotics 2021, 10, 745. https://doi.org/10.3390/antibiotics10060745 https://www.mdpi.com/journal/antibiotics