From Widespread Use to Loss of Effectiveness: The Consequences of Inappropriate Azithromycin Prescriptions During the...

We are aimed at evaluating whether the widespread use of azithromycin during the COVID-19 pandemic led to a significant increase in bacterial resistance compared with the prepandemic period and estimating the magnitude of this effect through a systematic review and meta-analysis.

This systematic review followed the PRISMA 2020 guidelines and Cochrane Handbook (Page,2021). Observational studies published between 2015 and 2025 reporting azithromycin resistance before and after the COVID-19 pandemic were identified. Odds ratios (ORs) were pooled using a random-effects model. Methodological quality was assessed using the Newcastle-Ottawa scale.

Eight studies met the eligibility criteria and were included in the quantitative synthesis. The meta-analysis demonstrated a significant increase in azithromycin resistance in the postpandemic period, with a pooled OR of 2.71 (95% CI: 2.04-3.59). Substantial heterogeneity was observed (I ² = 73.5%), justifying the use of a random-effects model.

The findings provide robust evidence that the excessive and largely empirical use of azithromycin during the COVID-19 pandemic contributed to a global rise in bacterial resistance. Strengthening antimicrobial stewardship policies is essential to preserve the clinical effectiveness of macrolides during future public health emergencies.