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

Background Antimicrobial stewardship (AMS) is essential for optimising antibiotic use and limiting antimicrobial resistance. The COVID-19 pandemic disrupted healthcare delivery, but its effect on early antibiotic review remains unclear. This study compared antibiotic review practices and prescribing patterns among hospitalised patients with respiratory tract infections before and during the pandemic.Methods A retrospective cohort study was conducted across two acute hospitals within an NHS Foundation Trust in England. Adults aged 25 years or older admitted with respiratory tract infections and prescribed systemic antibiotics were included from 2019 (pre-pandemic) and 2020 (pandemic). Data covered review timing, stewardship interventions based on the CARES framework, and prescribing patterns according to the WHO AWaRe classification. Stratified systematic random sampling identified 640 patients: 320 per year and 160 per hospital annually.Results Median age was 78 years in 2019 and 79 years in 2020. Mortality was comparable (15.0% versus 15.6%; p = 0.83). Early antibiotic review at 48–72 hours was maintained across both periods (51.6% versus 50.9%; p = 0.87). However, Watch antibiotic prescribing increased significantly from 52% to 60% (p < 0.001), accompanied by reduced Access antibiotic use, while Reserve use remained restricted (3–5%). Among guideline-concordant prescriptions, de-escalation was the most frequent intervention (19–38%). Continuation without documented change increased from 7% and 9% in 2019 to 21% and 16% in 2020 at Hospitals A and B, respectively.Conclusions Early antibiotic review remained resilient during COVID-19 despite operational pressures. Nevertheless, increased Watch prescribing highlights the need for enhanced diagnostic stewardship and pandemic-resilient AMS infrastructure. Embedded review processes, multidisciplinary collaboration, workforce development, and digital stewardship tools may strengthen antibiotic optimisation during future healthcare disruptions. The contribution of pharmacists requires further investigation. These findings demonstrate that maintaining review frequency alone may not prevent broader-spectrum prescribing and support targeted strategies to improve documentation, promote Access antibiotics, and preserve stewardship quality during periods of pressure.