Antibiotic Resistance After COVID-19

How did COVID-19 affect antibiotic resistance?

Antibiotics became a common part of hospital care early in the pandemic, despite having no activity against the virus responsible for COVID-19. CDC reports that almost 80% of patients hospitalized with COVID-19 received an antibiotic between March and October 2020. Clinicians faced uncertainty about accompanying bacterial infections, while hospitals managed staffing shortages, longer admissions and greater use of ventilators and catheters. These conditions created overlapping opportunities for resistant organisms to spread. The prescribing figure alone cannot establish how many prescriptions were unnecessary. [CDC's COVID-19 and antimicrobial resistance assessment](https://www.cdc.gov/antimicrobial-resistance/data-research/threats/covid-19.html).

A separate CDC update, first released in July 2024, examined six groups of resistant bacterial infections beginning during hospitalization. Their combined burden increased during the pandemic, peaked in 2021 and remained above the pre-pandemic baseline in 2022. Five of the six groups still had elevated rates in 2022; methicillin-resistant Staphylococcus aureus was the exception. These historical findings demonstrate that the setback extended beyond the first pandemic year. They do not establish the infection rate in October 2026 or isolate antibiotic prescribing as the sole cause. [CDC's analysis of antimicrobial resistance in 2021–2022](https://www.cdc.gov/antimicrobial-resistance/data-research/threats/update-2022.html).

When should someone with COVID-19 receive antibiotics?

The World Health Organization's June 2025 clinical management guideline recommends against starting empirical antibiotics in people with non-severe COVID-19 when suspicion of a concurrent bacterial infection is low. Empirical treatment means prescribing before the responsible organism has been confirmed. For severe COVID-19 with similarly low suspicion, WHO also suggests avoiding empirical antibiotics, although this recommendation is conditional. The distinction matters: severe viral illness alone does not establish a bacterial infection, and uncertainty about the evidence is greater in severely ill patients. [WHO's clinical management guideline](https://www.who.int/publications/i/item/B09467).

Once antibiotics have been started, the treatment decision needs review. CDC's hospital stewardship framework encourages clinicians to reconsider whether the illness will respond to antibiotics, whether appropriate cultures and diagnostic tests have been obtained, and whether treatment can be narrowed or stopped. A narrower antibiotic targets a smaller range of bacteria when the evidence supports that choice. The framework also addresses switching from intravenous to oral treatment and establishing an appropriate duration. These decisions belong with the treating team and should reflect the patient's evolving condition and test results. [CDC's hospital antibiotic stewardship framework](https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-h.pdf).

How can newer antibiotics help treat resistant infections?

Sulbactam-durlobactam, marketed as Xacduro, illustrates the approach. In May 2023, the FDA approved this intravenous combination for adults with hospital-acquired or ventilator-associated bacterial pneumonia caused by susceptible Acinetobacter baumannii-calcoaceticus complex bacteria. Sulbactam kills the bacteria, while durlobactam blocks certain enzymes that would otherwise destroy sulbactam. The approval covers a defined bacterial cause of pneumonia; it does not cover COVID-19 itself. Treatment also carries risks, including allergic reactions, liver test abnormalities and Clostridioides difficile-associated diarrhea. [FDA's Xacduro approval announcement](https://www.fda.gov/news-events/press-announcements/fda-approves-new-treatment-pneumonia-caused-certain-difficult-treat-bacteria).

The FDA's trial summary describes a study involving 177 hospitalized adults that compared Xacduro with colistin. Both groups also received imipenem-cilastatin to cover potential additional bacterial causes of pneumonia. The principal efficacy assessment examined deaths within 28 days among patients with confirmed carbapenem-resistant Acinetobacter infection. The FDA concluded that Xacduro met the trial's noninferiority criterion, meaning it satisfied the prespecified standard for not being unacceptably less effective than the comparator. That finding supports a specific treatment option; it does not establish effectiveness against every resistant infection. The practical implication is that drug development and accurate organism identification need to advance together. [FDA's Xacduro clinical trial summary](https://www.fda.gov/drugs/drug-approvals-and-databases/drug-trials-snapshots-xacduro).