ORIGINAL RESEARCH article
Front. Pharmacol.
Sec. Pharmacology of Infectious Diseases
Effectiveness and safety of a prospective audit and feedback-based antimicrobial stewardship program in hospitalized COVID-19 Patients: a quasi-experimental before-and-after study
Ariana Martínez-Suárez 1,2
Elena Salamanca-Rivera 3,4,5,6
Jaime Cordero-Ramos 1
Jesús Rodríguez-Baño 3,4,5,6
Pilar Retamar-Gentil 3,4,5,6
1. Hospital Pharmacy Department, University Hospital Virgen Macarena, Seville, Spain
2. Hospital Pharmacy Department, University Hospital Son Espases, Palma de Mallorca, Spain
3. Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena, Seville, Spain
4. Consortium for Biomedical Research in Infectious Diseases (CIBERINFEC), Madrid, Spain
5. Department of Medicine, University of Seville, Seville, Spain
6. Institute of Biomedicine of Seville (IBiS) and CSIC, Seville, Spain
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Abstract
Background: Antibiotic use among hospitalized patients with confirmed active SARS-CoV-2 infection is notably high (>70%) compared to the incidence of bacterial coinfections and superinfections (3.5% and 14.3%, respectively). Unjustified antimicrobial use poses preventable risks due to its toxicity and potential for long-term negative consequences. Antimicrobial Stewardship Programs (ASP) play a pivotal role in optimizing antibiotic therapy for COVID-19 patients. Methods: A quasi-experimental, before-and-after study was conducted to assess the impact of the COVID-ASP. The pre-ASP cohort included patients retrospectively, while the ASP cohort included patients prospectively, following the program implementation. The primary outcome was the evaluation of the impact of the COVID-ASP on DOT/1,000 patient-days. Secondary outcomes included the rate of antibiotics use, rate of inappropriate use, number of recommendations made, their acceptance rate, the incidence of Clostridioides difficile infection, 30-day mortality, and 30-day readmissions. Results: A total of 1,289 patients admitted were included, 561 (43.5%) in the pre-ASP cohort and 728 (56.5%) in the ASP cohort. The COVID-ASP cohort showed a significantly lower DOT/ 1,000 patient-days (162.96 vs. 105.71; p < 0.001). Additionally, the COVID-ASP was associated with a significant reduction in the rate of antibiotic use for suspected pneumonic coinfections (13.2% vs. 5.9%, p<0.001) and for all causes (17.5% vs. 12.5%, p=0.012) and for pneumonic superinfection (9.3% vs. 5.9%, p=0.022). No significant difference was observed in antibiotic use for superinfection from all causes (16.0% vs. 16.2%, p=0.936). The program also lowered inappropriate antibiotic use rate for suspected pneumonic coinfection (8.7% vs. 1.9%, p<0.001) and for all causes (10.3% vs. 4.0%, p<0.001), and for pneumonic superinfection (4.3% vs. 1.9%, p=0.013). However, it showed no impact on inappropriate antibiotic use in superinfections across all causes (5.9% vs. 5.2%, p=0.605). The most common recommendations included discontinuing antibiotics (58.6%) and adjusting the antibiotic regimen (30.3%). The program showed no significant effect on the incidence of Clostridioides difficile infections (0 vs. 0.1%, p=0.379), 30-day mortality (15.2% vs. 18.1%, p=0.156), or 30-day readmission rates (4.8% vs. 4.9%, p=0.469). Conclusion: In our experience, the three-step evaluation methodology allows for the evaluation of antibiotic prescriptions in patients with COVID-19 and allows for their optimization.
Summary
Keywords
antibiotics2, Antimicrobial stewardship1, feedback5, prospective audit4, SARS-CoV-23
Received
08 July 2025
Accepted
27 January 2026
Copyright
© 2026 Martínez-Suárez, Salamanca-Rivera, Cordero-Ramos, Rodríguez-Baño and Retamar-Gentil. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ariana Martínez-Suárez
Disclaimer
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