Clinical data from 1812 confirmed patients with COVID-19 admitted to four major tertiary care hospitals in Pakistan, that is, Pakistan Air Force Hospital, Islamabad, Pakistan Institute of Medical Sciences Hospital, Islamabad, Holy Family Hospital, Rawalpindi, and Benazir Bhutto Shaheed Hospital, Rawalpindi, were retrospectively collected during the period from February to August 2020.

Confirmed COVID-19 cases were defined as patients with a positive polymerase chain reaction test for COVID-19 from nasal and oropharyngeal swab samples taken at the time of admission to the hospital. Patients with incomplete data were excluded. Descriptive data of 1562 patients admitted during the months of May to July 2020 were abstracted and analyzed accordingly. The data included information about the patients’ age, gender, dates of admission and discharge (or death), medical history, presenting signs and symptoms, initial categorization of COVID-19 (mild, moderate, severe, and critical), and types of therapeutic agents (including but not limited to use of antibiotics, antimalarials, antivirals, antiparasitics, anticoagulants, and corticosteroids) used for treatment and management of COVID-19 during their hospital stay.

The statistical analysis was conducted using SPSS, version 24 (IBM Corporation) and Stata 16.1 (StataCorp LLC). Categorical variables were described using frequencies and percentages [33,34]. Chi-square tests and Fisher exact tests were used to compare percentages wherever appropriate. This retrospective cohort study was approved by the ethics review board of Rawalpindi Medical University. Data were collected with approval of the National Institute of Health (NIH), Pakistan.

Our results show that the highest proportion of admissions occurred in the month of June (846/1562, 54.2%), just after Eid-ul-Fitr (the Muslim festival, which was held on May 23 and 24 in 2020). It is worth noting that this was the time when the first wave of COVID-19 infections was at its peak in Pakistan; however, the trend of the treatment regimen remained the same during the period of the first wave [35-37]. However, after this period, a dramatic decrease in infections was observed due to effective precautions and regulations imposed by the government, including “smart lockdown” in potential hotspots, implementation of standard operating procedures, and closure of academic buildings [38].

Our study reports the use of up to 10 antibiotics of different classes. The effectiveness of the use of antibiotics for the treatment of COVID-19 is debatable, and evidence of their direct inhibitory effect on viral replication or pathogenesis remains to be proved. These antibiotics are generally used to treat upper respiratory tract infections, pneumonia, and other infections caused by opportunistic bacteria due to low immunity during viral infection. Azithromycin was widely used because it is a broad-spectrum antibiotic and can treat chest infections, including pneumonia, which is also a manifestation of COVID-19 infection; infections of the nose and throat, such as sinus infections (sinusitis); skin infections; Lyme disease; and some sexually transmitted infections [39].

In addition to antibiotics, some other frequently used drugs were anticoagulants (heparin and enoxaparin sodium) and corticosteroids (hydrocortisone and methylprednisolone). Use of anticoagulants and steroids is indicated for reduction of the inflammatory effects of SARS-CoV-2, which helps control disease progression to a limited extent; however, no succinct combination was observed in terms of treating COVID-19 [40].

Despite the fact that the antibiotics supported the combined therapies used against COVID-19, there is still no evidence that supports the use of these antibiotics to treat viral infection by health care professionals in Pakistan. Other drugs, such as anticoagulants and steroids, were also used as supportive therapy; however, there is a need to establish standard guidelines to treat patients with COVID-19–related complications. The experimental hit-and-trial approach of various combinations of drugs and the alarming frequency with which antibiotics were used will eventually lead to antibiotic resistance in the human population. One of the major challenges faced by health care professionals globally was the reliability on available therapies against the newly introduced virus. Mutations in RNA viruses are more frequent compared to those in DNA species; COVID-19, being an RNA virus, is a great threat to humanity. Modern research is necessary to study mutable infectious agents to develop multifaceted therapies to target the pathways of infection.

This study highlights the trend of drugs used to treat COVID-19 infections in early the months of the pandemic across Pakistan. The use of antibiotics by health care professionals to treat COVID-19 is questionable. It signifies the lack of specific guidelines that must be followed by all hospitals in terms of treatment regimens, and organizations such as the NIH and the Centers for Disease Control and Prevention must not only provide guidelines to address the pandemic but also ensure that those guidelines are strictly being followed throughout the country. This study reveals the weaknesses in the health care infrastructure and the inadequacy of hospitals and staff in Pakistan. With the second wave emerging in various countries and a mutant strain of SARS-CoV-2 causing infections, it is important to ensure that the standard operating procedures are being strictly followed, a proper treatment guideline is provided, and drugs used for symptomatic treatment are monitored to avoid antibiotic resistance in the future.

The study was limited to the Rawalpindi and Islamabad regions of Pakistan, which are large cities with relatively good health care facilities and checks and balances on health care practitioners. Data from other cities, especially small towns and rural regions, can be helpful in analyzing the misuse of medicines prescribed for treatment of COVID-19–related symptoms and complications. The study was performed on patients admitted in mid-2020 during the peak of the first wave, and a better analysis could be performed if data were taken from the months of the second wave as well. Collecting data during the first wave was difficult due to limited access to COVID-19 wards and a shortage of personal protection equipment. The number of subjects included in the study was under 2000; comprehensive information could be gathered from a large population size.