In 2019, a new type of coronavirus emerged in China and spread to the rest of the world, causing the World Health Organization to decree that there was a new pandemic in March 2020 (Cucinotta and Vanelli, 2020). The transmission of the new virus occurs through the respiratory route, with symptoms including fever, cough, runny nostrils, and atypical pneumonia; the latter is largely responsible for worsening the clinical condition of affected patients. Changes in taste and smell also completed the clinical condition of most patients affected by the new infection (Group, 2021).

With a mortality rate that ranged from up to 5% at the beginning of the pandemic to approximately 2.2% at the beginning of 2021 (Mallah et al., 2021), health authorities sought and continued seeking alternatives to prevent and combat the new coronavirus. Measures of social distancing, use of masks, closing schools and stores, and using hand sanitizer were the main measures adopted at the beginning of the pandemic, intending to reduce transmission rates, while there was no effective treatment or a vaccine able to reduce transmission and mortality rates among those affected (Morawska and Cao, 2020).

In 2020, with the exponential increase in the number of cases and the number of countries affected and, until that moment, without a vaccine available for everyone that could reduce the effects of the new virus, several treatment proposals were made based on re-purposed drugs that already had their safety established. Numerous drugs were identified as possible treatments, being the reason for many systematic reviews and meta-analyses (Kim et al., 2020; Budhathoki et al., 2021; Diaz-Arocutipa et al., 2021; Kumar et al., 2021).

Amongthe candidates for possible treatment, an association between azithromycin and hydroxychloroquine has been widely propagated and studied in combating new infections (Ghazy et al., 2020; Kim et al., 2020; Prodromos and Rumschlag, 2020; Siemieniuk et al., 2020; Kashour et al., 2021; Million et al., 2021). The anti-inflammatory and immunomodulatory properties of this macrolide directed its use as a possible candidate for the treatment of COVID-19 (Zarogoulidis et al., 2012). Studies, so far, do not show efficacy in the use of azithromycin associated with other drugs, in the treatment of COVID-19 (Cavalcanti et al., 2020; Furtado et al., 2020; Ghazy et al., 2020; Rosenberg et al., 2020; Fiolet et al., 2021)Using antibiotics, in a prophylactic or even therapeutic format, in addition to direct adverse effects, can lead to the emergence of resistant bacterial specimens in the medium and long term, as recently demonstrated (Doan et al., 2020).

The literature is scarce in studies that have analyzed the consumption of the main antibiotics prescribed in Brazil, with emphasis on azithromycin, prescribed throughout the national territory, during the pandemic. This study analyzed the sales data of the main antibiotics prescribed in Brazil to verify the change in consumption trends of these drugs during the COVID-19 pandemic.

Between January 2014 and July 2021, approximately 800 million packages containing antibiotics were sold in pharmacies and drugstores in Brazil. Amoxicillin, azithromycin, and cefalexin accounted for 67% of the sales (Table 1).

Amoxicillin, azithromycin, and cefalexin were the most commonly used antibiotics in Brazil during the period evaluated. There was an important seasonal variation for both amoxicillin and azithromycin, with an increase in DDD in the colder months of the southern hemisphere (June, July, and August). Both amoxicillin and azithromycin have been widely used for respiratory infections, which occur more frequently in the coldest months of the year (Young et al., 2020). The three most prescribed antibiotics in Brazil (cephalexin, azithromycin and amoxicillin) accounted for 2/3 of all prescriptions since 2014. Azithromycin and amoxicillin used as a first choice for respiratory infections together accounted for half of the antibiotics prescribed in the country (Laopaiboon et al., 2015). For cephalexin, with main indications for pregnant women and/or urinary infections, it represented only 16% of prescriptions.

The results showed an increase in the consumption of azithromycin during the pandemic, with statistically significant decreases in the consumption of amoxicillin and cefalexin during the pandemic. On the one hand, the decrease in the use of amoxicillin and cefalexin can reduce the levels of resistance to pathogens (Bruyndonckx and Coenen, 2021). An increase in azithromycin use will certainly have consequences on the resistance levels of pathogens causing acute respiratory infections (Bergman et al., 2006; Schroeder and Stephens, 2016). The significant increase (5.8% per month) in the consumption of azithromycin, especially at the beginning of the pandemic, showed a rush of the population towards a supposed “treatment.” Without the wide availability of a vaccine, the population sought drugs that could treat their COVID-19 infection, and reduce its intensity or lethality, without scientific proof.

During the pandemic, in Brazil, there was a decrease in prescriptions for amoxicillin and cefalexin. Cephalexin sales data remained stable throughout the pre-pandemic period (2014–2019), with small variations in DDDs (0.43–0.52), however, during the pandemic, sales data showed a significant reduction for about 0.36 DDDs. These decreases are clearly explained by the decrease in bacterial respiratory infections during the pandemic. Other authors found the same phenomenon, attributing the drop in respiratory infections (not COVID-19 infections) during the pandemic to social distancing (for example, schools closing), the use of face masks, decreased visits to doctors’ offices and emergency services, and measures of more restrictive health protocols during the pandemic (Kuitunen et al., 2020a; Kuitunen et al., 2020b; Chiapinotto et al., 2021; Huang, 2021). All these measures contributed to the decrease in the transmissibility of respiratory pathogens, with a consequent decrease in the number of infections and use of these antibiotics. The COVID-19 pandemic, despite all the problems it brought to humanity, also showed that appropriate health behaviors are important tools in combating infections, and consequently, the use of antibiotics and their consequences.

The increase in the overstated consumption of azithromycin has also occurred in other countries that have evaluated its use in the hospital setting (Castro-Lopes and Correia, 2021; Grau et al., 2021; Grau and Hernández, 2021; Sulis et al., 2021), showing similar increases to the present study, with a 2-fold higher consumption of azithromycin in the pandemic period than in previous periods.

Data referring to age group support the hypothesis that the consumption of azithromycin was directly related to the pandemic, as children, being less susceptible to COVID-19 infection (Gallo Marin et al., 2021; O'Driscoll et al., 2021), were those that showed a proportional decrease in consumption when compared to the age groups of adults (20 years or more). The same result was found by (Sulis et al., 2021) which showed that the increase in azithromycin sales in India during the pandemic also did not reach the lowest age groups.

The sudden increase in azithromycin sales to adults in Brazil can be explained by a search for a possible treatment for COVID-19. After the start of vaccination, these sales fall at the same rate as they rose. The consequences of this inappropriate use could impact the increase in resistance indicators of respiratory pathogens, the main target of this antibiotic.

Although Brazil has significantly advanced with the SNGPC system, as of 2013, controlling the sale of antibiotics only with the presentation and retention of the prescription, there is still much to be done in terms of pharmacologically educating antibiotic prescribers to use this class of drugs in a rational way to avoid the precocity of its ineffectiveness.

The measures forcibly adopted by the population (use of masks, social distance, hand sanitizer) also showed us that it is possible to reduce respiratory infections as hygiene measures and not just pharmacological measures. A smaller number of respiratory infections reflect a lower use of antibiotics, which equals the decrease in antimicrobial resistance indices.

The COVID-19 pandemic changed the pattern of antibiotic consumption in Brazil, with a decrease in the use of amoxicillin and cefalexin and an increase in the consumption of azithromycin. The unnecessary use of azithromycin may result in higher levels of resistance to respiratory pathogens, in addition to a false sense of protection against Covid. Actions worldwide to combat the inappropriate use of antibiotics are increasingly necessary so that the next pandemic is not caused by a multi-resistant bacterium.