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This study examines the link between antibiotic use and the proportion of resistant Escherichia coli bloodstream infections during the COVID-19 pandemic.

February 11, 2026Antibiotics0 citationsOpen Access

The Association Between Antibiotic Use and the Incidence of Third-Generation Cephalosporin-Resistance in Escherichia coli Bloodstream Infections: An Ecological Study

ACAdi Cohen ETElizabeth Temkin RSRamon Z. Shaban

Key Points

This study examines the link between antibiotic use and the proportion of resistant Escherichia coli bloodstream infections during the COVID-19 pandemic.
Utilized national surveillance data on bloodstream infections and antibiotic consumption from 2015 to 2023.
Performed interrupted time series analyses with a 1-year lag to assess COVID-19's impact.
Conducted linear regression to explore the association between antibiotic dosage and resistance rates.
Outpatient antibiotic use decreased by 19.4% during 2020, remaining 10.8% lower in 2023 than before the pandemic.
The incidence of E. coli bloodstream infections peaked in 2019 before declining and stabilizing post-pandemic.
A significant positive relationship was found between antibiotic use and the proportion of 3GC-resistant E. coli, with resistance increasing by 0.02 per defined daily dose of antibiotics.

Abstract

Background/Objectives: The COVID-19 period was marked by changes in antibiotic use and in the incidence of bacterial infections. We examined the association between antibiotic use and the proportion of Escherichia coli bloodstream infections (BSI) that were third-generation cephalosporin-resistant (3GC-R), using the COVID-19 period as a natural experiment. Methods: Data for this ecological study came from Israeli national surveillance systems for BSI and antibiotic consumption in 2015–2023. We performed interrupted time series analyses with a 1-year lag to examine the impact of COVID-19 on the proportion of E. coli BSI that were 3GC-R. We used linear regression to test the association between antibiotic use and 3GC resistance. Results: The majority of national antibiotic use was in outpatient settings; it was stable between 2015–2019, dropped by 19.4% in 2020, then increased gradually, but in 2023 remained 10.8% lower than before the pandemic. Incidence of E. coli BSI per 100,000 population increased from 62.6 in 2015 to a peak of 66.0 in 2019, with a small, non-significant change in the proportion of E. coli BSI that were 3GC-R (0.339 in 2015 vs. 0.335 in 2020). In 2020, the incidence of both 3GC-susceptible and 3GC-R E. coli BSI decreased. In 2021, only 3GC-R BSI declined, resulting in the proportion resistant dropping significantly by 0.05 (95% CI: 0.03–0.07). Post-pandemic, BSI incidence rose but remained below the 2019 rate. The proportion resistant after 2021 rose by 0.02 per year relative to the pre-COVID slope (95% CI: 0.02–0.03), such that it was higher in 2023 (0.341) than in 2019 and 2015. There was a significant positive linear relationship between antibiotic use and resistance: the proportion of E. coli BSI that were 3GC-R increased by 0.02 for each increase of one defined daily dose of antibiotic per person (95% CI: 0.001–0.03). Conclusions: Reduced outpatient antibiotic use during COVID-19 was followed by a reduction in the proportion of E. coli BSI that were 3GC-R.

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