Azithromycin use before and during the COVID- 19 pandemic and the impact of implementing national evidence-based guidelines in Qatar

Background: Initial small, uncontrolled studies suggested a beneficial effect of azithromycin in individuals with COVID-19.However, subsequent studies have not confirmed its effectiveness.We assessed azithromycin usage before and during the pandemic in a national healthcare system in Qatar and the impact of implementation of evidence-based guidelines upon prescription rates.Methods: Using electronic medical records, we retrieved all azithromycin prescriptions from 2019 to 2022 at the public healthcare system in Qatar which provides over 85 % of healthcare in Qatar.Azithromycin prescription numbers and rates/100,000 population were calculated and compared over time.A course was defined as any azithromycin prescription for 5 days with no gap of >10 days.Courses were considered COVID-19-related if prescribed -3 to +10 days post positive SARS-CoV-2 PCR.Prescription rates before and after the pandemic, and before and after evidence-based guidelines implementation (in June 2020) were compared.Results: During the study period, 203,806 azithromycin courses were prescribed to 166,062 individuals.Overall number of courses increased in the first 2 quarters of 2020 (average 12,857/quarter in 2019 to average of 19,297 in Q1-Q2 of 2020) and then dropped to 9881/quarter over the next 6 quarters.COVID-19 related azithromycin courses peaked in.2020-Q2 (13,691) and dropped to 2836 for 2020-Q3, 1410 for 2020-Q4; 5465 for 2021-Q1, and 4288 for 2021-Q2.Stringent COVID-19 guidelines in June 2020 rapidly reduced azithromycin usage.Conclusions: Azithromycin prescriptions increased immediately after the COVID-19 pandemic, but rapidly declined immediately after implementing evidence-based guidelines.Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) precipitated a global health crisis, straining healthcare systems worldwide.Since its initial identification in late 2019, COVID-19 has spread rapidly, resulting in millions of infections and significant morbidity and mortality. 1ntibiotics, particularly azithromycin, received significant attention as potential adjunctive therapies in the management of COVID-19.Azithromycin, a macrolide antibiotic with immunomodulatory properties, was initially reported to exert antiviral effects and mitigate inflammatory responses associated with COVID-19 pneumonia in a small observational study. 2 However, numerous subsequent randomized controlled trials and systematic reviews failed to demonstrate any efficacy of azithromycin, [3][4][5] with at least one meta-analysis indicating an elevated mortality risk associated to the concurrent administration of azithromycin and hydroxychloroquine. 6Reports indicate overutilization and inappropriate administration of azithromycin during the