Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals

In-hospital use of antibiotics in internal medicine: A cross-sectional study before, during and after the COVID-19 pandemic in a COVID-19-free ward

BACKGROUND

Coronavirus Disease-19 (COVID-19) pandemic impacted the use of antibiotics in hospitalized patients. However, most data on antibiotic therapy (AT) were recorded in COVID-19 settings. This study analyzed the appropriateness of AT in the real-world scenario of a COVID-19-free internal medicine ward before, during, and after the pandemic.

METHODS

Clinical information of hospitalized patients was collected, and data related to AT prescription were analyzed. The appropriateness of AT was independently assessed by two specialists in internal medicine and infectious disease, combining evidence-based guidelines with a validated tool.

RESULTS

Records of 1249 patients were analyzed: AT was prescribed in 229 (55.2 %) patients before, 134 (53.2 %) patients during, and 315 (54.1 %) patients after COVID-19 pandemic. Compared to the pre-pandemic period, there was a decrease in monotherapy with 3rd and 4th generation cephalosporins and fluoroquinolones, and an increase in β-lactams + β-lactamase inhibitors and antibiotic combinations. Furthermore, AT was longer and more expensive during the pandemic, with duration and cost remaining higher after its end. The inappropriateness of AT increased during and after COVID-19 pandemic. Compared to the pre-pandemic period, inappropriate AT was longer and more expensive than appropriate AT. The COVID-19 pandemic had a significant impact on changes related to AT type and antibiotic classes.

CONCLUSIONS

The COVID-19 pandemic increased the inappropriateness of AT in a COVID-19-free internal medicine ward. Most modifications persist despite the end of pandemic, potentially leading to negative effects on in-hospital antimicrobial resistance. There is an urgent need to re-establish antimicrobial stewardship policies to address the longer-term global threat of antimicrobial resistance.

Use of antibiotics in the early COVID-19 pandemic in Poland, the Netherlands and Spain, from erraticism to (more) logic

INTRODUCTION

In the Spring of 2020, the world was hit with unparalleled impact by the coronavirus pandemic. Antibiotics were widely used, even without good rationale. The aim of our study was to compare the use of antibiotics in patients with confirmed COVID-19 from three hospitals across Europe (Poland, the Netherlands and Spain) between two subsequent periods in the early days of the pandemic.

METHOD

We analysed data (antibiotics used and variation in the use of antibiotics, patients, admission and disease-related characteristics) from 300 patients admitted in three hospitals (University Hospital in Cracow, University Medical Center in Utrecht and Vall d'Hebron University Hospital in Barcelona) with confirmed infection of SARS-CoV-2 during Q1 2020 and Q4 2020.

RESULTS

There was ample variation in terms of patient mix and outcomes across the 3 hospitals. The majority of patients (225 out of 300) in all 3 hospitals received at least 1 antibiotic during the hospitalisation period. A minority of patients (68 out of 300) had their bacterial test results positive during their hospitalisation period. Throughout the 2 study periods, third-generation cephalosporins (ceftriaxone in 170 out of 300 patients) emerged as the most commonly used class of antibiotics. There was an apparent shift towards more rational utilisation of antibiotics, in all three hospitals.

CONCLUSIONS

Our study shows that during the early stage of COVID-19 pandemic in 2020, antibiotics were frequently used in three European teaching hospitals despite the relatively low incidence of microbiologically confirmed bacterial infections. While in the early days of the COVID-19 pandemic antibiotic prescribing was full of trial and error, we could also confirm a learning curve over time.

Impact of COVID-19 pandemic on the utilization and quality of antibiotic use in the primary care setting in England, March 2019-March 2023: a segmented interrupted time series analysis of over 53 million individuals

BACKGROUND

Amid the COVID-19 pandemic, we evaluated the short-term impact of COVID-19 on antibiotic use in primary care in England, focusing on both antibiotic quantity (overuse) and quality (misuse) of use.

RESEARCH DESIGN AND METHODS

A population-based segmented interrupted analysis was applied on monthly dispensed antibiotics prescriptions using the Prescription Cost Analysis dataset (March/2019-March/2023). The quantity was assessed using number of items dispensed per 1000 inhabitants (NTI) and defined daily doses per 1000 inhabitants per day (DID), while quality was evaluated using WHO's Access Watch Reserve (AWaRe) classification, the proportion of '4C' antibiotics and the percentage of broad- to narrow-spectrum antibiotics.

RESULTS

Findings indicate 8.6 (17.2%) and 0.4 (2.6%) increase in the NTI and DID, respectively, with a statistically significant uptick in trend noted after the second lockdown (β5) for 'total antibiotics' for NTI only (β5 = 1.6; 95% CI:0.17, 3.1). Quality assessment showed an increase in 'Access' antibiotics from 77% in March/2019 to 86% in March/2023; however, COVID-19 had no significant impact on WHO AWaRe classes.

CONCLUSION

COVID-19's impact on antibiotic use quality and quantity appeared to be minimal, though an increase in utilization post-second lockdown coincided with healthcare system recovery. This suggests a nuanced impact of the pandemic, highlighting the importance of continued antimicrobial stewardship.

Impact of the COVID-19 pandemic on the utilisation and quality of antibiotic use in the Scottish primary care setting: a population-based segmented interrupted time-series analysis

BACKGROUND

Inappropriate use of antibiotics is expected to increase during the COVID-19 pandemic, but there are limited data on COVID-19's long-term impact. We assessed the impact of COVID-19 on the quantity and quality of antibiotic use in Scotland.

RESEARCH DESIGN AND METHODS

A segmented interrupted time series was applied to monthly dispensed antibiotics using prescription cost analysis data from March/2019 to March/2023. Antibiotic use was quantified using the number of items dispensed/1000 inhabitants (TIDs) and defined daily dose/1000 inhabitants/day (DIDs). The quality of antibiotic use was assessed using key quality indicators including the WHO AWaRe classification, proportion of broad-spectrum and "4C"-antibiotics.

RESULTS

Overall, for all antibiotics, there was a non-significant increase in TIDs and DIDs before the first lockdown (March/2020) (β1), but a decline in the level immediately after the first (β2) and second lockdowns (β4) (November/2020), albeit non-significant. However, a significant increase in the time trend after the second lockdown (β5) for all antibiotic classes was observed. COVID-19 had no negative impact on AWaRe utilisation, with the proportion of all antibiotics from the Access group increasing from 76% in March/2019 to 90% in March/2023. The proportion of "4C" antibiotic reduced significantly after the second lockdown.

CONCLUSIONS

Neither the utilisation nor the quality of total antibiotic use appeared to have been significantly affected by COVID-19.

Physicians' irrational attitudes on the antibiotic prescribing for the treatment of COVID-19 in Turkey: A multicenter survey

BACKGROUND

The inappropriate and excessive use of antibiotics during the coronavirus pandemic has become an important issue.

OBJECTIVE

Our primary aim is to ascertain the attitudes of physicians toward the antibiotics prescribing for the treatment of COVID-19 in Turkey. Our secondary aim was to identify factors affecting to physicians' decisions regarding antibiotic therapy for the treatment of COVID-19 and risk factors associated with antibiotic overprescribing.

METHODS

It was a multicenter cross-sectional survey. Physicians from 63 different cities were invited to survey through social media (Facebook, Instagram, WhatsApp). Data were collected from respondents through an online questionnaires during November-December 2021.

RESULTS

The survey was completed by 571 participants from 63 cities. Pulmonologists comprised the majority (35.20%), followed by internal medical specialists (27.85%) and general practitioners (23.29%). The rates of participants who started empirical antibiotics in the outpatient, ward, and ICU (intensive care unit) were 70.2%, 85.5%, and 74.6%, respectively. When the practice of prescribing antibiotics by physicians for the treatment of COVID-19 in outpatients was compared according to the healthcare setting (primary, secondary, tertiary care hospitals) no significant difference was found. Sputum purulence (68.2%) was recognized as the most important factor for the decision of antibiotic therapy, followed by procalcitonin levels (64.9%) and abnormal radiological findings (50.3%). The most prescribed antibiotics were respiratory quinolones. (48%, 65.9%, 62.7% outpatient, ward, ICU respectively) CONCLUSIONS: In this study, we found that physicians frequently had irrational attitudes toward antibiotic prescription to COVID-19 patients, including those with minor diseases. Our findings underline that the necessity of particular, workable interventions to guarantee the prudent use of antibiotics in COVID-19.

The impact of COVID-19 on antibiotic resistance and clinical outcomes among critically ill patients

BACKGROUND

There is conflicting evidence regarding the impact of the Coronavirus 2019 (COVID-19) pandemic on antimicrobial resistance, with few studies conducted in low- and middle-income countries. We investigated the impact of the COVID-19 pandemic on multidrug resistant organisms (MDROs) among critically ill patients and their clinical outcomes.

METHODS

This was a retrospective observational study of patients admitted to the medical Intensive Care Unit at Jordan University Hospital and had blood, urine, or bronchoalveolar bacterial cultures taken during 2 time periods: prepandemic (ie, 1/2016 to 1/2019) and pandemic (ie, 1/2020 to 1/2023). We compared the clinical outcomes (ie, in-hospital deaths, the need for O2 devices, intubation, the length of hospital stay, and the occurrence of complications) and prevalence of MDROs between the 2 periods and conducted multivariate analyses.

RESULTS

There were 1,254 patients (479 prepandemic and 775 postpandemic. The percentage of patients who had MDROs was significantly higher among patients with a culture taken during the pandemic (82.4%) compared to before it (17.6%) (P-value=.000). Multivariate analysis demonstrated that patients cultured during the pandemic were more than 3 times as likely to have an MDRO (odds ratio = 3.210; 95% confidence interval: 2.236-4.609).

CONCLUSIONS

The increase in MDROs during the COVID-19 pandemic is an alarming threat to public health; thus, investigating the antibiotic resistance situation as the pandemic subsides is crucial.

Community antibiotic prescribing in patients with COVID-19 across three pandemic waves: a population-based study in Scotland, UK

OBJECTIVES

This study aims to examine community antibiotic prescribing across a complete geographical area for people with a positive COVID-19 test across three pandemic waves, and to examine health and demographic factors associated with antibiotic prescribing.

DESIGN

A population-based study using administrative data.

SETTING

A complete geographical region within Scotland, UK.

PARTICIPANTS

Residents of two National Health Service Scotland health boards with SARS-CoV-2 virus test results from 1 February 2020 to 31 March 2022 (n=184 954). Individuals with a positive test result (n=16 025) had data linked to prescription and hospital admission data ±28 days of the test, general practice data for high-risk comorbidities and demographic data.

OUTCOME MEASURES

The associations between patient factors and the odds of antibiotic prescription in COVID-19 episodes across three pandemic waves from multivariate binary logistic regression.

RESULTS

Data included 768 206 tests for 184 954 individuals, identifying 16 240 COVID-19 episodes involving 16 025 individuals. There were 3263 antibiotic prescriptions ±28 days for 2395 episodes. 35.6% of episodes had a prescription only before the test date, 52.3% of episodes after and 12.1% before and after. Antibiotic prescribing reduced over time: 20.4% of episodes in wave 1, 17.7% in wave 2 and 12.0% in wave 3. In multivariate logistic regression, being female (OR 1.31, 95% CI 1.19 to 1.45), older (OR 3.02, 95% CI 2.50 to 3.68 75+ vs <25 years), having a high-risk comorbidity (OR 1.45, 95% CI 1.31 to 1.61), a hospital admission ±28 days of an episode (OR 1.58, 95% CI 1.42 to 1.77) and health board region (OR 1.14, 95% CI 1.03 to 1.25, board B vs A) increased the odds of receiving an antibiotic.

CONCLUSION

Community antibiotic prescriptions in COVID-19 episodes were uncommon in this population and likelihood was associated with patient factors. The reduction over pandemic waves may represent increased knowledge regarding COVID-19 treatment and/or evolving symptomatology.

Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

INTRODUCTION

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

METHODS

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

RESULTS

A total of 284 patients were included, most were male (66.9%), aged 30-50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the 'Watch' category (90.8%) followed by the 'Reserve' category (4.8%), similar to previous COVID-19 waves.

CONCLUSION

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

Exploring factors shaping antibiotic resistance patterns in Streptococcus pneumoniae during the 2020 COVID-19 pandemic

Non-pharmaceutical interventions implemented to block SARS-CoV-2 transmission in early 2020 led to global reductions in the incidence of invasive pneumococcal disease (IPD). By contrast, most European countries reported an increase in antibiotic resistance among invasive Streptococcus pneumoniae isolates from 2019 to 2020, while an increasing number of studies reported stable pneumococcal carriage prevalence over the same period. To disentangle the impacts of the COVID-19 pandemic on pneumococcal epidemiology in the community setting, we propose a mathematical model formalizing simultaneous transmission of SARS-CoV-2 and antibiotic-sensitive and -resistant strains of S. pneumoniae. To test hypotheses underlying these trends five mechanisms were built into the model and examined: (1) a population-wide reduction of antibiotic prescriptions in the community, (2) lockdown effect on pneumococcal transmission, (3) a reduced risk of developing an IPD due to the absence of common respiratory viruses, (4) community azithromycin use in COVID-19 infected individuals, (5) and a longer carriage duration of antibiotic-resistant pneumococcal strains. Among 31 possible pandemic scenarios involving mechanisms individually or in combination, model simulations surprisingly identified only two scenarios that reproduced the reported trends in the general population. They included factors (1), (3), and (4). These scenarios replicated a nearly 50% reduction in annual IPD, and an increase in antibiotic resistance from 20% to 22%, all while maintaining a relatively stable pneumococcal carriage. Exploring further, higher SARS-CoV-2 R0 values and synergistic within-host virus-bacteria interaction mechanisms could have additionally contributed to the observed antibiotic resistance increase. Our work demonstrates the utility of the mathematical modeling approach in unraveling the complex effects of the COVID-19 pandemic responses on AMR dynamics.

Antimicrobial consumption in an acute NHS Trust during the COVID-19 pandemic: intervention time series analysis

Objective

To determine the impact of the COVID-19 pandemic on antimicrobial consumption and trends of therapeutic drugs for COVID-19 treatments, including corticosteroids, remdesivir and monoclonal antibodies (tocilizumab) from April 2017 to September 2022 in a secondary care NHS Trust in England.

Methods

A retrospective intervention time series analysis was conducted for April 2017 to September 2022 at the Mid Yorkshire Teaching NHS Trust. Data were retrieved from the pharmacy dispensing system as defined daily doses (DDDs) monthly and reported per 1000 occupied bed days (OBDs). Antimicrobial consumption and COVID-19 treatment options were measured. DDDs were calculated according to the classification of antimicrobials for systemic use (J01) and for other drugs classification. Trends for antimicrobial consumption and other therapeutic drugs for treating COVID-19 were also determined in each wave in England.

Results

During the pandemic: total antibiotic consumption decreased from 826.4 to 728.2 DDDs per 1000 OBDs (P = 0.0067); piperacillin/tazobactam use increased (P < 0.0001) and ciprofloxacin use decreased (P < 0.0001); there were no changes in Access, Watch, Reserve antibiotic use, and the proportion of antifungal consumption was consistent throughout the study. The use of total antibiotics (P = 0.024), levofloxacin (P = 0.0007), piperacillin/tazobactam (P = 0.0015) and co-amoxiclav (P = 0.0198) increased during wave one. Consumption of COVID-19 treatment drugs was highest during wave two, with 624.3 DDDs per 1000 OBDs for dexamethasone (P = 0.4441), 6.8 DDDs per 1000 OBDs for remdesivir (P < 0.0001) and 35.01 DDDs per 1000 OBDs for tocilizumab (P = 0.2544).

Discussion

This study determined the consumption of antimicrobials trends before and during the pandemic. The individual wave antimicrobial consumption indicates maximum consumption in the first wave, advocating for antimicrobial stewardship and preparedness for future pandemics.

Antibiotic use in hospitalized patients with COVID-19: a population-based study in Hong Kong

Background

Hong Kong experienced four epidemic waves caused by the ancestral strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in 2020-2021 and a large Omicron wave in 2022. Few studies have assessed antibacterial prescribing for coronavirus disease 2019 (COVID-19) inpatients throughout the pandemic.

Objectives

To describe inpatient antibacterial prescribing and explore factors associated with their prescription.

Methods

Electronic health records of patients with COVID-19 admitted to public hospitals in Hong Kong from 21 January 2020 to 30 September 2022 were used to assess the prevalence and rates of inpatient antibacterial drug use (days of therapy/1,000 patient days [DOT/1,000 PD]). We used multivariable logistic regression to investigate potential associations between patients' baseline characteristics and disease severity and prescription of an antibacterial drug during hospital admission.

Results

Among 65,810 inpatients with COVID-19, 54.0% were prescribed antibacterial drugs (550.5 DOT/1,000 PD). Compared to waves 1-2 (46.7%; 246.9 DOT/1,000 PD), the prescriptions were lowest during wave 4 (28.0%; 246.9; odds ratio (OR): 0.39, 95% CI: 0.31-0.49) and peaked in early wave 5 (64.6%; 661.2; 0.82, 0.65-1.03). Older age (≥80 years: OR 2.66, 95% CI, 2.49-2.85; 60-79 years: 1.59, 1.51-1.69, compared with 20-59 years), more severe disease (fatal: 3.64, 3.2-4.16; critical: 2.56, 2.14-3.06, compared with severe), and COVID-19 vaccine doses (two doses: 0.74, 0.69-0.78; three doses: 0.69, 0.64-0.74; four doses: 0.52, 0.44-0.62, compared with unvaccinated) were associated with inpatient antibacterial drug use.

Conclusions

Antibacterial prescribing changed over time for hospitalized patients with confirmed COVID-19 and was potentially related to patients' demographics, medical conditions, and COVID-19 vaccination status as well as healthcare capacity during epidemic waves.

Using risk factors and markers to predict bacterial respiratory co-/superinfections in COVID-19 patients: is the antibiotic steward's toolbox full or empty?

BACKGROUND

Adequate diagnosis of bacterial respiratory tract co-/superinfection (bRTI) in coronavirus disease (COVID-19) patients is challenging, as there is insufficient knowledge about the role of risk factors and (para)clinical parameters in the identification of bacterial co-/superinfection in the COVID-19 setting. Empirical antibiotic therapy is mainly based on COVID-19 severity and expert opinion, rather than on scientific evidence generated since the start of the pandemic.

PURPOSE

We report the best available evidence regarding the predictive value of risk factors and (para)clinical markers in the diagnosis of bRTI in COVID-19 patients.

METHODS

A multidisciplinary team identified different potential risk factors and (para)clinical predictors of bRTI in COVID-19 and formulated one or two research questions per topic. After a thorough literature search, research gaps were identified, and suggestions concerning further research were formulated. The quality of this narrative review was ensured by following the Scale for the Assessment of Narrative Review Articles.

RESULTS

Taking into account the scarcity of scientific evidence for markers and risk factors of bRTI in COVID-19 patients, to date, COVID-19 severity is the only parameter which can be associated with higher risk of developing bRTI.

CONCLUSIONS

Evidence on the usefulness of risk factors and (para)clinical factors as predictors of bRTI in COVID-19 patients is scarce. Robust studies are needed to optimise antibiotic prescribing and stewardship activities in the context of COVID-19.

Impact of COVID-19 on healthcare-associated infections: Antimicrobial consumption does not follow antimicrobial resistance

BACKGROUND

This study aimed to analyze the Healthcare-Associated Infections (HAI) rates and antimicrobial consumption in Intensive Care Units (ICU) in São Paulo city during the COVID-19 pandemic and compare them with the pre-pandemic period.

METHODS

This cohort included all hospitals that reported HAI rates (Central-Line-Associated Bloodstream Infection ‒ CLABSI and Ventilator-Associated Pneumonia ‒ VAP), the proportion of microorganisms that caused CLABSI, the proportion of resistant microorganisms, and antimicrobial consumption from January 2017 ‒ December 2020. Hospitals were stratified by the number of beds, Central Venous Catheter (CVC) utilization rate, Mechanical-Ventilation (MV) utilization rate, and type of funding. Statistical analyses were based on time-series plots and regression models.

RESULTS

220 ICUs were included. The authors observed an abrupt increase in CLABSI rates after the pandemic onset. High CLABSI rates during the pandemic were associated with hospital size, funding (public and non-profit private), and low CVC use (≤ 50%). An increase in VAP rates was associated with public hospitals, and high MV use (> 35%). The susceptibility profile of microorganisms did not differ from that of the pre-pandemic period. polymyxin, glycopeptides, and antifungal use increased, especially in COVID-19 ICUs.

CONCLUSIONS

HAI increased during COVID-19. The microorganisms' susceptibility profile did not change with the pandemic, but the authors observed a disproportionate increase in large-spectrum antimicrobial drug use.

Antibiotic use among admitted pediatric patients in the United States with status asthmaticus before and during the COVID-19 pandemic

OBJECTIVE

Hospital admission trends of children with status asthmaticus diminished during the Coronavirus-19 (COVID-19) pandemic of 2020, possibly secondary to several factors such as school closures and use of face masks. What effect this had on antibiotic prescribing practices has yet to be described. The objective of our study was to evaluate the use of antibiotics in hospitalized children with a diagnosis of status asthmaticus before and during the COVID pandemic.Methods: A retrospective cross-sectional analysis was conducted using the TriNetX® cloud-based program with a national and institutional database. Each database was queried for all inpatient pediatric encounters from 3 to 18 years old, admitted with a diagnosis of status asthmaticus in the spring seasons of 2017-2019. Admission data and antibiotic usage were queried during the COVID-19 pandemic year of 2020 from both databases and compared amongst all study years.Results: In 2020, there was an overall decrease in the number of admissions as compared to the average number from 2017-2019, by 76.9% in the national database (p < 0.05) and 91.2% in the institutional database. The rates of antibiotic prescriptions significantly dropped among the national database (p < 0.001, z = 3.39) and remained non-significantly changed among the institutional database (p = 0.944 and z = 0.073).Conclusions: Our study demonstrates that the COVID-19 pandemic year of 2020 coincided with a significant decrease in hospital admissions and antibiotic prescribing prevalence among children with status asthmaticus on a national level. Nonetheless, our reported trends in antibiotic prescribing are still grossly similar to that of pre-pandemic times and may demonstrate a continued need for antimicrobial stewardship.

Evaluation of duration of antibiotic therapy across hospitals in Scotland including the impact of COVID-19 pandemic: a segmented interrupted time series analysis

BACKGROUND

Little is known about the duration of antibiotic use in hospital settings. We evaluated the duration of hospital antibiotic therapy for four commonly prescribed antibiotics (amoxicillin, co-amoxiclav, doxycycline, and flucloxacillin) including the assessment of COVID-19 impact.

METHODS

A repeated, cross-sectional study using the Hospital Electronic Prescribing and Medicines Administration system (January/2019-March/2022). Monthly median duration of therapy/duration categories was calculated, stratified by routes of administration, age, and sex. The impact of COVID-19 was assessed using segmented time-series analysis.

RESULTS

There were significant variations in the median duration of therapy across routes of administration (P < 0.05), with the highest value among those antibiotic courses composed of both oral and IV antibiotics ('Both' group). Significantly higher proportions of prescriptions within the 'Both' group had a duration of >7 days compared to oral or IV. The duration of therapy differed significantly by age. Some small statistically significant changes in the level/trends of duration of therapy were observed in the post-COVID-19 period.

CONCLUSIONS

No evidence for prolonged duration of therapy were observed, even during COVID-19 pandemic. The duration of IV therapy was relatively short, suggesting timely clinical review and consideration of IV to oral switch. Longer duration of therapy was observed among older patients.

Risk factors for nosocomial COVID-19 in a French university hospital

OBJECTIVES

Prevention strategies implemented by hospitals to reduce nosocomial transmission of SARS-CoV-2 sometimes failed. Our aim was to determine the risk factors for nosocomial COVID-19.

PATIENTS AND METHODS

A case-control study was conducted (September 1, 2020-January 31, 2021) with adult patients hospitalized in medical or surgical units. Infants or patients hospitalized in ICU were excluded. Cases were patients with nosocomial COVID-19 (clinical symptoms and RT-PCR+ for SARS-CoV-2 or RT-PCR+ for SARS-CoV-2 with Ct ≤28 more than 5days after admission); controls were patients without infection (RT-PCR- for SARS-CoV-2 >5 days after admission). They were matched according to length of stay before diagnosis and period of admission. Analyses were performed with a conditional logistic regression.

RESULTS

A total of 281 cases and 441 controls were included. In the bivariate analysis, cases were older (OR per 10years: 1.22; 95%CI [1.10;1.36]), had more often shared a room (OR: 1.74; 95%CI [1.25;2.43]) or a risk factor for severe COVID-19 (OR: 1.94; 95%CI [1.09;3.45]), were more often hospitalized in medical units [OR: 1.59; 95%CI [1.12;2.25]), had higher exposure to contagious health care workers (HCW; OR per 1person-day: 1.12; 95%CI [1.08;1.17]) and patients (OR per 1 person-day: 1.11; 95%CI [1.08;1.14]) than controls. In an adjusted model, risk factors for nosocomial COVID-19 were exposure to contagious HCW (aOR per 1person-day: 1.08; 95%CI [1.03;1.14]) and to contagious patients (aOR per 1person-day: 1.10; 95%CI [1.07;1.13]).

CONCLUSIONS

Exposure to contagious professionals and patients are the main risk factors for nosocomial COVID-19.

Antimicrobial stewardship implementation before and during the COVID-19 pandemic in the acute care settings: a systematic review

INTRODUCTION

Antibiotics are widely administered for various indications, leading to increased antimicrobial resistance (AMR) in acute care hospitals. Since the onset of the COVID-19 pandemic, Antimicrobial Stewardship (AMS) effective strategies should be used to maintain the rational use of antibiotics and decrease the threat of Antimicrobial Resistance (AMR).

AIM

This systematic literature review aims to investigate the AMS intervention Before-the-pandemic (BP) and During-the-pandemic (DP) from the literature.

DESIGN AND SETTING

Systematic literature review of primary studies on AMS implementation in acute care settings.

METHODS

Relevant studies published between 2000 and March 2021 were obtained from Medline (via PubMed), OVID, CINAHL, International Pharmaceutical Abstracts, Psych Info, Scopus, Web of Science, Cochrane Library, OpenGrey, and Google Scholar, using a comprehensive list of search terms. Public Health England (PHE) toolkit was agreed upon as a gold standard for the AMS implementation.

RESULTS

There were 8763 articles retrieved from the databases. Out of these, 13 full-text articles met the inclusion criteria for the review. The AMS implementation was identified in the included studies into AMS strategies (Core strategies & Supplemental strategies), and AMS measures BP and DP.

CONCLUSION

This Systematic literature review summarises AMS implementation strategies and measures all over the previous 20 years of research. There are many lessons learnt from COVID-19 pandemic. The proper selection of the AMS implementation strategies and measures appeared to be effective in maintaining the appropriate use of antibiotics and decreasing the AMR threat, especially during the COVID-19 pandemic. Further studies are required to provide empirical data to evaluate the AMS implementation and identify which of these strategies and measures were effective BP and DP. In order to be prepared for any emergency/crisis or future pandemics.

Use of Systemic Antibiotics in Patients with COVID-19 in Colombia: A Cross-Sectional Study

Antibiotics are frequently prescribed to patients with COVID-19. The aim was to determine the pattern of use of systemic antibiotics in a group of patients diagnosed with COVID-19 in Colombia between 2020-2022. This was a descriptive cross-sectional study designed to identify antibiotics prescription patterns for patients diagnosed with COVID-19 treated in eight clinics in Colombia. The AWaRe tool of the World Health Organization (WHO) was used to classify the antibiotics. A total of 10,916 patients were included. The median age was 57 years, and 56.4% were male. A total of 57.5% received antibiotics, especially ampicillin/sulbactam (58.8%) and clarithromycin (47.9%). Most of the antibiotics were classified as Watch (65.1%), followed by Access (32.6%) and Reserve (2.4%). Men (OR: 1.29; 95%CI: 1.17-1.43), older adults (OR: 1.67; 95%CI: 1.48-1.88), patients with dyspnea (OR: 1.26; 95%CI: 1.13-1.41), rheumatoid arthritis (OR: 1.94; 95%CI: 1.17-3.20), and high blood pressure at admission (OR: 1.45; 95%CI: 1.29-1.63), patients treated in-hospital (OR: 5.15; 95%CI: 4.59-5.77), patients admitted to the ICU (OR: 10.48; 95%CI: 8.82-12.45), patients treated with systemic glucocorticoids (OR: 3.60; 95%CI: 3.21-4.03) and vasopressors (OR: 2.10; 95%CI: 1.60-2.75), and patients who received invasive mechanical ventilation (OR: 2.37; 95%CI: 1.82-3.09) were more likely to receive a systemic antibiotic. Most of the patients diagnosed with COVID-19 received antibiotics, despite evidence showing that bacterial coinfection is rare. Antibiotics from the Watch group predominated, a practice that goes against WHO recommendations.

Bacterial co-infection and antibiotic stewardship in patients with COVID-19: a systematic review and meta-analysis

INTRODUCTION

Understanding the proportion of patients with COVID-19 who have respiratory bacterial co-infections and the responsible pathogens is important for managing COVID-19 effectively while ensuring responsible antibiotic use.

OBJECTIVE

To estimate the frequency of bacterial co-infection in COVID-19 hospitalized patients and of antibiotic prescribing during the early pandemic period and to appraise the use of antibiotic stewardship criteria.

METHODS

Systematic review and meta-analysis was performed using major databases up to May 5, 2021. We included studies that reported proportion/prevalence of bacterial co-infection in hospitalized COVID-19 patients and use of antibiotics. Where available, data on duration and type of antibiotics, adverse events, and any information about antibiotic stewardship policies were also collected.

RESULTS

We retrieved 6,798 studies and included 85 studies with data from more than 30,000 patients. The overall prevalence of bacterial co-infection was 11% (95% CI 8% to 16%; 70 studies). When only confirmed bacterial co-infections were included the prevalence was 4% (95% CI 3% to 6%; 20 studies). Overall antibiotic use was 60% (95% CI 52% to 68%; 52 studies). Empirical antibiotic use rate was 62% (95% CI 55% to 69%; 11 studies). Few studies described criteria for stopping antibiotics.

CONCLUSION

There is currently insufficient evidence to support widespread empirical use of antibiotics in most hospitalised patients with COVID-19, as the overall proportion of bacterial co-infection is low. Furthermore, as the use of antibiotics during the study period appears to have been largely empirical, clinical guidelines to promote and support more targeted administration of antibiotics in patients admitted to hospital with COVID-19 are required.

Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications

The COVID-19 pandemic has significantly influenced antimicrobial use in hospitals, raising concerns regarding increased antimicrobial resistance (AMR) through their overuse. The objective of this study was to assess patterns of antimicrobial prescribing during the current COVID-19 pandemic among hospitals in Pakistan, including the prevalence of COVID-19. A point prevalence survey (PPS) was performed among 11 different hospitals from November 2020 to January 2021. The study included all hospitalized patients receiving an antibiotic on the day of the PPS. The Global-PPS web-based application was used for data entry and analysis. Out of 1024 hospitalized patients, 662 (64.64%) received antimicrobials. The top three most common indications for antimicrobial use were pneumonia (13.3%), central nervous system infections (10.4%) and gastrointestinal indications (10.4%). Ceftriaxone (26.6%), metronidazole (9.7%) and vancomycin (7.9%) were the top three most commonly prescribed antimicrobials among surveyed patients, with the majority of antibiotics administered empirically (97.9%). Most antimicrobials for surgical prophylaxis were given for more than one day, which is a concern. Overall, a high percentage of antimicrobial use, including broad-spectrums, was seen among the different hospitals in Pakistan during the current COVID-19 pandemic. Multifaceted interventions are needed to enhance rational antimicrobial prescribing including limiting their prescribing post-operatively for surgical prophylaxis.

The impact of COVID-19 on multidrug-resistant organisms causing healthcare-associated infections: a narrative review

Coronavirus disease 2019 (COVID-19) changed healthcare across the world. With this change came an increase in healthcare-associated infections (HAIs) and a concerning concurrent proliferation of MDR organisms (MDROs). In this narrative review, we describe the impact of COVID-19 on HAIs and MDROs, describe potential causes of these changes, and discuss future directions to combat the observed rise in rates of HAIs and MDRO infections.

Assessment of drugs administered in the Middle East as part of the COVID-19 management protocols

The pandemic spread of coronavirus (COVID-19) has been reported first at the end of 2019. It continues disturbing various human aspects with multiple pandemic waves showing more fatal novel variants. Now Egypt faces the sixth wave of the pandemic with controlled governmental measures. COVID-19 is an infectious respiratory disease-causing mild to moderate illness that can be progressed into life-threatening complications based on patients- and variant type-related factors. The symptoms vary from dry cough, fever to difficulty in breathing that required urgent hospitalization. Most countries have authorized their national protocols for managing manifested symptoms and thus lowering the rate of patients' hospitalization and boosting the healthcare systems. These protocols are still in use even with the development and approval of several vaccines. These protocols were instructed to aid home isolation, bed rest, dietary supplements, and additionally the administration of antipyretic, steroids, and antiviral drugs. The current review aimed to highlight the administered protocols in the Middle East, namely in Egypt and the Kingdom of Saudi Arabia demonstrating how these protocols have shown potential effectiveness in treating patients and saving many soles.

COVID-19 Mixed Impact on Hospital Antimicrobial Stewardship Activities: A Qualitative Study in UK-Based Hospitals

Antimicrobial resistance (AMR) is a well-known global threat due to the subsequent increase in antimicrobial usage. Several antimicrobial stewardship (AMS) strategies have been implemented to curb irrational prescribing and reduce the AMR burden. However, since the beginning of the COVID-19 pandemic, it has enormously impacted the healthcare system and jeopardized public health, causing millions of deaths globally. Our semi-structured qualitative study aimed to explore the impact of COVID-19 on AMS activities in the UK hospitals. Seventeen interviews were conducted with health care professionals who were part of AMS teams (consultant medical microbiologists, infectious disease consultants, antimicrobial pharmacists). Interviews were audio-recorded and transcribed. An inductive thematic framework was adopted to analyse and create the themes. After agreement of the hierarchical framework definition, all transcripts were coded accordingly. Four main themes and 15 sub-themes were identified. These main themes were: (1) AMS activities or strategies before and during the pandemic; (2) challenges to implementing AMS activities before and during the pandemic; (3) information from public authorities on AMS during the pandemic; and (4) new AMS activities/strategies adopted during the pandemic. Staff vacancies, redeploying of AMS staff to other duties and meeting the burden related to the COVID-19 and lack of resources were the most frequently identified contributing factors to withheld AMS activities during the pandemic. However, modifications to the hybrid working environment, i.e., remote or flexible working, allowed for resumption of AMS activities including virtual ward rounds, virtual meetings and other activities. Further research needs to assess the impact of the hybrid delivery system on AMS activities.

Effect of asthma, COPD, and ACO on COVID-19: A systematic review and meta-analysis

Introduction

The prevalence of asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap (ACO) in patients with COVID-19 varies, as well as their risks of mortality. The present study aimed to assess the prevalence of asthma, COPD, and ACO as comorbidities, and to determine their risks of mortality in patients with COVID-19 using a systematic review and meta-analysis.

Methods

We systematically reviewed clinical studies that reported the comorbidities of asthma, COPD, and ACO in patients with COVID-19. We searched various databases including PubMed (from inception to 27 September 2021) for eligible studies written in English. A meta-analysis was performed using the random-effect model for measuring the prevalence of asthma, COPD, and ACO as comorbidities, and the mortality risk of asthma, COPD, and ACO in patients with COVID-19 was estimated. A stratified analysis was conducted according to country.

Results

One hundred one studies were eligible, and 1,229,434 patients with COVID-19 were identified. Among them, the estimated prevalence of asthma, COPD, and ACO using a meta-analysis was 10.04% (95% confidence interval [CI], 8.79–11.30), 8.18% (95% CI, 7.01–9.35), and 3.70% (95% CI, 2.40–5.00), respectively. The odds ratio for mortality of pre-existing asthma in COVID-19 patients was 0.89 (95% CI, 0.55–1.4; p = 0.630), while that in pre-existing COPD in COVID-19 patients was 3.79 (95% CI, 2.74–5.24; p<0.001). France showed the highest prevalence of asthma followed by the UK, while that of COPD was highest in the Netherlands followed by India.

Conclusion

Pre-existing asthma and COPD are associated with the incidence of COVID-19. Having COPD significantly increases the risk of mortality in patients with COVID-19. These differences appear to be influenced by the difference of locations of disease pathophysiology and by the daily diagnosis and treatment policy of each country.

Protective effects of amoxicillin and probiotics on colon disorders in an experimental model of acute diverticulitis disease

Acute diverticulitis disease is associated with inflammation and infection in the colon diverticula and may lead to severe morbidity. This study aimed to evaluate and compare the protective effects of amoxicillin antibiotic, either alone or in combination with probiotics (Lactobacillus acidophilus and Bifidobacterium lactis), in a rat model of acute diverticulitis disease. Acute diverticulitis was induced, in albino rats, by adding 3% weight/volume of dextran sulfate sodium (DSS) to the rats’ drinking water; daily for 7 days, in addition to injecting lipopolysaccharide (LPS) enema (4 mg/kg). The impact of treatments was assessed by measuring the physiological and immunological parameters and evaluating colon macroscopic and microscopic lesions. The results showed that both treatments (especially probiotics with amoxicillin) alleviated the adverse effects of DSS and LPS. This was obvious through the modulation of the rats’ body weight and the colon weight-to-length ratio. Also, there was a significant (p < 0.001) decrease in the colon macroscopic lesion score. The pro-inflammatory cytokines [(TNF)-α, (IL)-1β, (IFN)-γ, and (IL)-18]; in the colon tissue; were significantly (p < 0.001) decreased. Also, both treatments significantly ameliorated the elevation of myeloperoxidase activity and C-reactive protein levels, in addition to improving the histopathological alterations in the colon tissue. In conclusion, amoxicillin and probiotics–amoxicillin were effective in preventing the development of experimentally induced acute diverticulitis, through their anti-inflammatory and immunomodulatory effects. Furthermore, this study has explored the role of probiotics in preventing DSS/LPS-induced acute diverticulitis, so it can be applied as a promising treatment option for acute diverticulitis disease.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Antibiotic Use among Patients Hospitalized with COVID-19 and Treated in Three Different Clinics

Objective

In this study, we aimed to determine and compare the rates of empirical antibiotic use and duration between the chest diseases clinic (CDC), infectious disease clinic (IDC), and internal medicine clinic (IMC) among patients hospitalized because of COVID-19.

Methods

This cross-sectional study was performed in a single university hospital. The study included all patients aged 18 years and older hospitalized with a PCR-confirmed COVID-19 between May 30, 2021, and August 30, 2021. Clinical and laboratory findings were recorded from the electronic medical records database.

Results

The study included a total of 581 inpatients, of whom 310 (53.4%) were women. Of the 581 patients, 475 (81.8%) were prescribed antibiotics. The rate of antibiotic prescription was 71.6% for IDC, 88.5% for CDC, and 87.4% for IMC. The most commonly used antibiotic was moxifloxacin in all groups. The mean treatment duration was 8.9±6.16 days. The mean duration of antibiotic treatment was 11.1±5.90 days for CDC, 11.3±6.74 days for IMC, and 5.3 days±3.76 for IDC.

Conclusion

Patients with COVID-19 who were treated in IDC had a lower rate and shorter duration of antibiotic use compared to the other clinics. However, the rate of antibiotic prescription in all three groups was very high. Therefore, antimicrobial management programs should be meticulously conducted to reduce unnecessary antibiotic use.

Characterization of the expressed RNA variants from young patients with critical and non-critical SARS-CoV-2 infection

Background

Since the COVID-19 outbreak emerged, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has continuously evolved into variants with underlying mutations associated with increased transmissibility, potential escape from neutralizing antibodies, and disease severity. Although intensive research is ongoing worldwide to understand the emergence of SARS-CoV-2 variants, there is a lack of information on what constitutes the expressed RNA variants in critical and non-critical comorbidity-free young patients. The study sought  to characterize the expressed RNA variants from young patients with critical and non-critical forms of SARS-CoV-2 infection.

Methodology

The bulk ribonucleic acid (RNA) sequencing data with the identifier GSE172114 were downloaded from the Gene Expression Omnibus (GEO) database. The study participants were divided into critical, n = 46, and non-critical, n = 23. FastQC version 0.11.9 and Cutadapt version 3.7 were used to assess the read quality and perform adapter trimming, respectively. Spliced Transcripts Alignment to a Reference (STAR) version 2.7.10a was used to align reads to the human (hg38) reference genome. Genome Analysis Tool Kit (GATK) best practice was followed to call variants using the rnavar pipeline, part of the nf-core pipelines.

Results

Our research demonstrates that critical and non-critical SARS-CoV-2-infected individuals are characterized by a unique set of expressed RNA variants. The expressed gene variants are enriched on the innate immune response, specifically neutrophil-mediated immune response. On the other hand, the expressed gene variants are involved in both innate and cellular immune responses.

Conclusion

Deeply phenotyped comorbidity-free young patients with critical and non-critical SARS-CoV-2 infection are characterized by a unique set of expressed RNA variants. The findings in this study can inform the patient classification process in health facilities globally when admitting young patients infected with SARS-CoV-2.

COVID-19 associated multisystemic mucormycosis from India: a multicentric retrospective study on clinical profile, predisposing factors, cumulative mortality and factors affecting outcome

PURPOSE

The clinical course of COVID-19 has been complicated by secondary infections, including bacterial and fungal infections. The rapid rise in the incidence of invasive mucormycosis in these patients is very much concerning. COVID-19-associated mucormycosis was detected in huge numbers during the second wave of the COVID-19 pandemic in India, with several predisposing factors indicated in its pathogenesis. This study aimed to evaluate the epidemiology, predisposing factor, cumulative mortality and factors affecting outcomes among the coronavirus disease COVID-19-associated mucormycosis (CAM).

METHODS

A multicenter retrospective study across three tertiary health care centers in Southern part of India was conducted during April-June 2021.

RESULTS

Among the 217 cases of CAM, mucormycosis affecting the nasal sinuses was the commonest, affecting 95 (44%) of the patients, orbital extension seen in 84 (38%), pulmonary (n = 25, 12%), gastrointestinal (n = 6, 3%), isolated cerebral (n = 2) and disseminated mucormycosis (n = 2). Diabetes mellitus, high-dose systemic steroids were the most common underlying disease among CAM patients. The mucormycosis-associated case-fatality at 6 weeks was 14%, cerebral or GI or disseminated mucormycosis had 9 times higher risk of death compared to other locations. Extensive surgical debridement along with sequential antifungal drug treatment improved the survival in mucormycosis patients.

CONCLUSION

Judicious and appropriate management of the predisposing factor and factors affecting mortality associated with CAM with multi-disciplinary approach and timely surgical and medical management can be much helpful in achieving a successful outcome.

Antifungal therapy in the management of fungal secondary infections in COVID-19 patients: A systematic review and meta-analysis

Objectives

The prevalence of fungal secondary infections among COVID-19 patients and efficacy of antifungal therapy used in such patients is still unknown. Hence, we conducted this study to find the prevalence of fungal secondary infections among COVID-19 patients and patient outcomes in terms of recovery or all-cause mortality following antifungal therapy (AFT) in such patients.

Methods

We performed a comprehensive literature search in PubMed^®, Scopus^®, Web of Sciences^™, The Cochrane Library, ClinicalTrial.gov, MedRxiv.org, bioRxiv.org, and Google scholar to identify the literature that used antifungal therapy for the management fungal secondary infections in COVID-19 patients. We included case reports, case series, prospective & retrospective studies, and clinical trials. Mantel Haenszel random-effect model was used for estimating pooled risk ratio for required outcomes.

Results

A total of 33 case reports, 3 case series, and 21 cohort studies were selected for final data extraction and analysis. The prevalence of fungal secondary infections among COVID-19 patients was 28.2%. Azoles were the most commonly (65.1%) prescribed AFT. Study shows that high survival frequency among patients using AFT, received combination AFT and AFT used for >28 days. The meta-analysis showed, no significant difference in all-cause mortality between patients who received AFT and without AFT (p = 0.17), between types of AFT (p = 0.85) and the duration of AFT (p = 0.67).

Conclusion

The prevalence of fungal secondary infections among COVID-19 patients was 28.2%. The survival frequency was high among patients who used AFT for fungal secondary infections, received combination AFT and AFT used for >28 days. However, meta-analysis results found that all-cause mortality in COVID-19 patients with fungal secondary infections is not significantly associated with type and duration of AFT, mostly due to presence of confounding factors such as small number of events, delay in diagnosis of fungal secondary infections, presence of other co-infections and multiple comorbidities.

Occurrence and outcomes of possible superadded infections in older adults with COVID-19-cohort study

Aim

To investigate the outcomes and prevalence of superadded infections in older adults with COVID-19.

Findings

Possible superadded infection is common in older adults hospitalized with COVID-19 and was associated with longer inpatient stay and higher mortality.

Message

Clinicians should have a low threshold to assess for other sources of infection in older adults with COVID-19.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00675-9.

Purpose

Current guidance discourages use of antibiotics in COVID-19. However, in older adults, superadded infection may be common and require treatment. Our aim was to investigate the occurrence and outcomes from possible superadded infections, occurring within 2 weeks of hospitalization, in older adults with COVID-19.

Methods

This was a single centre, observational cohort study. We collected data from patients admitted to older adult wards who had tested positive for the Sars-CoV-2 virus on viral PCR between 1st October and 1st December 2020. The primary outcome was inpatient death occurring within 90 days of COVID-19 diagnosis. The secondary outcome was length of stay in hospital. Associations were described using univariable and multivariable models, and time to event data.

Results

Of 266 patients with COVID-19, 43% (115) had evidence of superadded infections (91 with positive bacterial cultures and 36 instances of radiological lobar consolidation). Patients with superadded infections were more likely to die (45.2 versus 30.7%, p = 0.020) and had an increased length of stay (23 versus 18 days, p = 0.026).

Conclusions

Recommendations to avoid antibiotics in COVID-19 may not be applicable to an older adult population. Assessing for possible superadded infections is warranted in this group.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00675-9.

Impact of COVID-19 on Antimicrobial Resistance in Paediatric Population: a Narrative Review

Purpose of Review

Irrational use of antimicrobials has been reported in paediatric population during the COVID-19 time period. This may lead to potential development of antimicrobial resistance and increased morbidity and mortality among this vulnerable population. The purpose of this review is to ascertain the impact of COVID-19 pandemic on antimicrobial resistance among paediatrics and the possible strategies to minimize the menace of antimicrobial resistance.

Recent Findings

Recent findings indicate that the COVID-19 pandemic has direct as well as indirect impact on the development of antimicrobial resistance among paediatric population.

Summary

This review article shows the impact of COVID-19 on the development of antimicrobial resistance and strategies to prevent it with special reference to antimicrobial stewardship programmes among paediatric population.

Co-Infections, Secondary Infections, and Antimicrobial Use in Patients Hospitalized with COVID-19 during the First Five Waves of the Pandemic in Pakistan; Findings and Implications

Background: COVID-19 patients are typically prescribed antibiotics empirically despite concerns. There is a need to evaluate antibiotic use among hospitalized COVID-19 patients during successive pandemic waves in Pakistan alongside co-infection rates. Methods: A retrospective review of patient records among five tertiary care hospitals during successive waves was conducted. Data were collected from confirmed COVID-19 patients during the first five waves. Results: 3221 patients were included. The majority were male (51.53%), residents from urban areas (56.35%) and aged >50 years (52.06%). Cough, fever and a sore throat were the clinical symptoms in 20.39%, 12.97% and 9.50% of patients, respectively. A total of 23.62% of COVID-19 patients presented with typically mild disease and 45.48% presented with moderate disease. A high prevalence of antibiotic prescribing (89.69%), averaging 1.66 antibiotics per patient despite there only being 1.14% bacterial co-infections and 3.14% secondary infections, was found. Antibiotic use significantly increased with increasing severity, elevated WBCs and CRP levels, a need for oxygen and admittance to the ICU; however, this decreased significantly after the second wave (p < 0.001). Commonly prescribed antibiotics were piperacillin plus an enzyme inhibitor (20.66%), azithromycin (17.37%) and meropenem (15.45%). Common pathogens were Staphylococcus aureus (24.19%) and Streptococcus pneumoniae (20.96%). The majority of the prescribed antibiotics (93.35%) were from the WHO’s “Watch” category. Conclusions: Excessive prescribing of antibiotics is still occurring among COVID-19 patients in Pakistan; however, rates are reducing. Urgent measures are needed for further reductions.

Antibiotic use in patients with Coronavirus disease 2019 (COVID-19): outcomes and associated factors

OBJECTIVES

To characterise the factors, outcomes and infections associated with antibiotic use in COVID-19 patients.

METHODS

Records of patients with RT-PCR-confirmed COVID-19, hospitalized at the CHU Charleroi (Belgium) between 11 March and 3 May 3 2020, were retrospectively reviewed. Factors associated with antibiotic treatment, outcomes and bacterial infections were analysed.

RESULTS

Among the 164 hospitalized COVID-19 patients (median age 60.5 years [IQR] 46-79), twenty-five (15.2%) were admitted to the ICU. Twenty-six (15.9%) died in the hospital. One hundred (61%) received antibiotic treatment. Combination therapies with macrolides were more common in the early part of the study period (26/67, 38.8%). Twenty-eight patients (17.1%) had a confirmed infection, mostly of the urinary tract (18/28, 64.3%). Only 2 (1.2%) had a documented respiratory coinfection. Six of the 7 ICU infections (85.7%) were superinfections. Gram-negative bacteria were most frequently isolated. In multivariate analysis, six factors were associated with antibiotic use: being hospitalized in the ICU (OR: 4.59; 95% CI 1.07-19.71), age > 65 years (OR: 4.16; 95% CI 1.72-10.05), arrival from a nursing home (OR: 4.59; 95% CI 1.11-19.71), diabetes (OR: 4.35; 95% CI 1.26-14.93), bilateral consolidation on chest CT (OR: 9.92; 95% CI 2.40-41.06) and a C-reactive protein level > 60 mg/L (OR:2.46; 95% CI 1.13-5.37). Antibiotic treatment did not reduce the length of stay or the mortality rate.

CONCLUSION

Antibiotics have been overused during the COVID-19 pandemic, despite a low rate of coinfections . Integrating the antimicrobial stewardship (AMS) programme into the COVID-19 response is essential.

Antimicrobial Prescribing Patterns in Patients with COVID-19 in Russian Multi-Field Hospitals in 2021: Results of the Global-PPS Project

The COVID-19 pandemic is a global public health challenge with understudied effects on antimicrobial usage. We aimed to analyze antimicrobial prescribing patterns in COVID-19 patients in Russian multi-field hospitals by means of the Global-PPS Project developed by the University of Antwerp. Out of 999 patients in COVID-19 wards in six hospitals surveyed in 2021, 51.3% received antimicrobials (79% in intensive care, 47.5% in medical wards). Systemic antivirals and antibiotics were prescribed to 31% and 35.1% of patients, respectively, and a combination of both to 14.1% of patients. The top antivirals administered were favipiravir (65%), remdesivir (19.2%), and umifenovir (15.8%); the top antibiotics were ceftriaxone (29.7%), levofloxacin (18%), and cefoperazone/sulbactam (10.4%). The vast majority of antibiotics was prescribed for treatment of pneumonia or COVID-19 infection (59.3% and 25.1%, respectively). Treatment was based on biomarker data in 42.7% of patients but was targeted only in 29.6% (6.7% for antibiotics). The rate of non-compliance with guidelines reached 16.6%. Antimicrobial prescribing patterns varied considerably in COVID-19 wards in Russian hospitals with groundlessly high rates of systemic antibiotics. Antimicrobial usage surveillance and stewardship should be applied to inpatient care during the COVID-19 pandemic.

A Retrospective Analysis of the Bacterial Infections, Antibiotic Use, and Mortality Predictors of COVID-19 Patients

Purpose

This study aimed to investigate the rate and profile of bacterial infections, mortality-associated predictors, and report the most common microorganisms and antibiotic use in coronavirus disease-19 (COVID-19) patients.

Patients and Methods

This study used a retrospective approach to evaluate the bacterial culture, antibiotic use, comorbidities, imaging, and laboratory discoveries of patients with COVID-19 (hospitalized) confirmed by reverse transcription polymerase chain reaction (RT-PCR) between May and December 2020. We have selected 906 COVID-19 positive patients using a consecutive sampling technique and analyzed data using IBM SPSS-22 statistical software. Statistical analysis included univariate, bivariate, and multivariate analysis. It was carried out using multivariable logistic regression analysis to predict the mortality of COVID-19 patients.

Results

A total of 410 patients, which involved 247 males with a mean age of 53.9 years were evaluated. Based on the results, the positive bacterial culture was detected in 18.3% of all patients who sent the culture sample test, representing bacterial infections. The Acinetobacter baumannii was the most commonly identified organism, while the proportion of patients treated with antibiotics was 83.4%. Furthermore, azithromycin was prescribed in the highest number of patients with approximately 44.3% of all antibiotics. The total mortality rate was 39.8% and its ratio was higher in COVID-19 patients with bacterial infections (65.3%, X² = 25.1, P<0.001). Patients mortality who used antibiotics were also higher compared to those who did not (89% vs 11%, P<0.014). Age, length of hospitalization, bacterial infection, shortness of breath, neutrophil-to-lymphocyte ratio (NLR), and diabetes mellitus were also associated predictors to increased hospital mortality (adjusted OR (aOR) 0.382, P<0.013; aOR 4.265, P<0.001; aOR 3.720, P<0.001; aOR 3.889, P<0.001; aOR 6.839, P<0.003; aOR 1.844, P<0.030), respectively.

Conclusion

This study discovered that there is high use of antibiotics amongst COVID-19 patients; however, the bacterial infection rates did not exceed one-fifth of the total patients. Furthermore, older age, bacterial infections, a longer length of hospitalization, diabetes mellitus, shortness of breath, and higher NLR have a significant impact on the mortality of COVID-19 patients.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

Antibiotic prescribing patterns among patients admitted to an academic teaching hospital for COVID-19 during the first wave of the pandemic in Toronto: A retrospective, controlled study

BACKGROUND

Empirical antibiotics are not recommended for coronavirus disease 2019 (COVID-19).

METHODS

In this retrospective study, patients admitted to Toronto General Hospital's general internal medicine from the emergency department for COVID-19 between March 1 and August 31, 2020 were compared with those admitted for community-acquired pneumonia (CAP) in 2020 and 2019 in the same months. The primary outcome was antibiotics use pattern: prevalence and concordance with COVID-19 or CAP guidelines. The secondary outcome was antibiotic consumption in days of therapy (DOT)/100 patient-days. We extracted data from electronic medical records. We used logistic regression to model the association between disease and receipt of antibiotics, linear regression to compare DOT.

RESULTS

The COVID-19, CAP 2020, and CAP 2019 groups had 67, 73, and 120 patients, respectively. Median age was 71 years; 58.5% were male. Prevalence of antibiotic use was 70.2%, 97.3%, and 90.8% for COVID-19, CAP 2020, and CAP 2019, respectively. Compared with CAP 2019, the adjusted odds ratio (aOR) for receiving antibiotics was 0.23 (95% CI 0.10 to 0.53, p = 0.001) and 3.42 (95% CI 0.73 to 15.95, p = 0.117) for COVID-19 and CAP 2020, respectively. Among patients receiving antibiotics within 48 hours of admission, compared with CAP 2019, the aOR for guideline-concordant combination regimens was 2.28 (95% CI 1.08 to 4.83, p = 0.031) for COVID-19, and 1.06 (95% CI 0.55 to 2.05, p = 0.856) for CAP 2020. Difference in mean DOT/100 patient-days was -24.29 (p = 0.009) comparing COVID-19 with CAP 2019, and +28.56 (p = 0.003) comparing CAP 2020 with CAP 2019.

CONCLUSIONS

There are opportunities for antimicrobial stewardship to address unnecessary antibiotic use.

SARS-CoV-2-Legionella Co-Infections: A Systematic Review and Meta-Analysis (2020-2021)

Legionnaires' Disease (LD) is a severe, sometimes fatal interstitial pneumonia due to Legionella pneumophila. Since the inception of the SARS-CoV-2 pandemic, some contradictory reports about the effects of lockdown measures on its epidemiology have been published, but no summary evidence has been collected to date. Therefore, we searched two different databases (PubMed and EMBASE) focusing on studies that reported the occurrence of LD among SARS-CoV-2 cases. Data were extracted using a standardized assessment form, and the results of such analyses were systematically reported, summarized, and compared. We identified a total of 38 articles, including 27 observational studies (either prospective or retrospective ones), 10 case reports, and 1 case series. Overall, data on 10,936 SARS-CoV-2 cases were included in the analyses. Of them, 5035 (46.0%) were tested for Legionella either through urinary antigen test or PCR, with 18 positive cases (0.4%). A pooled prevalence of 0.288% (95% Confidence Interval (95% CI) 0.129-0.641), was eventually calculated. Moreover, detailed data on 19 co-infections LD + SARS-CoV-2 were obtained (males: 84.2%; mean age: 61.9 years, range 35 to 83; 78.9% with 1 or more underlying comorbidities), including 16 (84.2%) admissions to the ICU, with a Case Fatality Ratio of 26.3%. In summary, our analyses suggest that the occurrence of SARS-CoV-2-Legionella infections may represent a relatively rare but not irrelevant event, and incident cases are characterized by a dismal prognosis.

Antimicrobial Use in Hospitalised Patients with COVID-19: An International Multicentre Point-Prevalence Study

Studies suggest that the incidence of coinfections in patients with the coronavirus disease 2019 (COVID-19) is low, but a large number of patients receive antimicrobials during hospitalisation. This may fuel a rise in antimicrobial resistance (AMR). We conducted a multicentre point-prevalence survey in seven tertiary university hospitals (in medical wards and intensive care units) in Croatia, Italy, Serbia and Slovenia. Of 988 COVID-19 patients, 521 were receiving antibiotics and/or antifungals (52.7%; range across hospitals: 32.9–85.6%) on the day of the study. Differences between hospitals were statistically significant (χ2 (6, N = 988) = 192.57, p < 0.001). The majority of patients received antibiotics and/or antifungals within 48 h of admission (323/521, 62%; range across hospitals: 17.4–100%), their most common use was empirical (79.4% of prescriptions), and pneumonia was the main indication for starting the treatment (three-quarters of prescriptions). The majority of antibiotics prescribed (69.9%) belonged to the “Watch” group of the World Health Organization AWaRe classification. The pattern of antimicrobial use differed across hospitals. The data show that early empiric use of broad-spectrum antibiotics is common in COVID-19 patients, and that the pattern of antimicrobial use varies across hospitals. Judicious use of antimicrobials is warranted to prevent an increase in AMR.

The landscape of antibiotic usage among COVID-19 patients in the early phase of pandemic: a Malaysian national perspective

Background

During the early phase of the COVID-19 pandemic, antibiotic usage among COVID-19 patients was noted to be high in many countries. The objective of this study was to determine the prevalence of antibiotic usage and factors affecting antibiotic usage among COVID-19 patients during the early phase of the COVID-19 pandemic in Malaysia.

Methods

This was a cross-sectional study that involved reviewing medical records of COVID-19 Malaysian patients aged 12 and above who were diagnosed with COVID-19 and received treatment in 18 COVID-19 hospitals from February to April 2020. A minimum sample of 375 patients was required. A binary logistic regression analysis was performed to determine factors associated with antibiotic usage. Variables with p < 0.05 were considered statistically significant.

Results

A total of 4043 cases were included for analysis. The majority of the patients (87.6%) were non-smokers, male (65.0%), and had at least one comorbidity (37.0%). The median age was 35 years (IQR: 38). The prevalence of antibiotic usage was 17.1%, with 5.5% of them being prescribed with two or more types of antibiotics. The most frequent antibiotics prescribed were amoxicillin/clavulanic acid (37.8%), ceftriaxone (12.3%), piperacillin/tazobactam (13.3%), azithromycin (8.3%), and meropenem (7.0%). Male patients (adjusted OR 1.53), who had a comorbidity (adjusted OR 1.36), associated with more severe stage of COVID-19 (adjusted OR 6.50–37.06), out-of-normal range inflammatory blood parameters for neutrophils, lymphocytes, and C-reactive protein (adjusted OR 2.04–3.93), corticosteroid use (adjusted OR 3.05), and ICU/HDU admission (adjusted OR 2.73) had higher odds of antibiotic use.

Conclusions

The prevalence of antibiotic usage in the early phase of the COVID-19 pandemic was low, with amoxicillin/clavulanic acid as the most common antibiotic of choice. The study showed that clinicians rationalized antibiotic usage based on clinical assessment, supported by relevant laboratory parameters.

Comparison of antibiotic use in the COVID-19 pandemic with the pre-pandemic period in a university hospital

INTRODUCTION

The appropriate use of antibiotics is an important strategy in slowing the development of antimicrobial resistance. This study aimed to evaluate antibiotic consumption and antibiotic use during the coronavirus disease 2019 (COVID-19) pre-pandemic period and pandemic period.

METHODS

Antibiotic consumption was evaluated with the antibiotic consumption index (ACI).

RESULTS

Antibiotics with the largest increase in ACI value during the pandemic period compared to the previous year increased from 0.4 to 1.8 DDI/100 bed days in moxifloxacin. Teicoplanin, linezolid, and clindamycin were not affected in terms of consumption.

CONCLUSIONS

It was observed that the use of many intravenous antibiotics in our hospital increased during the pandemic period.

Improving management and antimicrobial stewardship for bacterial and fungal infections in hospitalized patients with COVID-19

SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) infection is being one of the most significant challenges of health care systems worldwide. Bacterial and fungal infections in hospitalized patients with coronavirus disease 2019 (COVID-19) are uncommon but consumption of antibiotics and antifungals has increased dramatically during the ongoing pandemic resulting in increased selective pressure for global antimicrobial resistance. Nosocomial bacterial superinfections appear to be more frequent than community-acquired coinfections, particularly among patients admitted to the intensive care unit (ICU) and those receiving immunosuppressive treatment. Fungal infections associated with COVID-19 might be missed or misdiagnosed. Existing and new antimicrobial stewardship (AMS) programmes can be utilized directly in COVID-19 pandemic and are urgently needed to contain the high rates of misdiagnosis and antimicrobial prescription. The aim of this review is to describe the role of bacterial and fungal infections and possible strategies of AMS to use in daily practice for optimal management of COVID-19.

Antimicrobial consumption in patients with COVID-19: a systematic review and meta-analysis

INTRODUCTION

Since the onset of the pandemic, prescribing antimicrobials has become a common practice to treat patients infected with COVID-19.

AREAS COVERED

A systematic literature search was performed in the electronic databases MEDLINE, CINAHL, WHO COVID-19 database, including EMBASE, Scopus, WHO-COVID, LILACS, and Google Scholar to identify original articles published up to 31 July 2021. A random-effects model was used to estimate the pooled prevalence or proportion of antimicrobial consumption among COVID-19 patients.

EXPERT OPINION

We identified 43 original articles, 33 studies from high-income countries, six from upper-middle-income countries, and four from lower-middle-income countries. Most of the studies presented data from hospital or secondary health-care settings (n = 34). Included studies measured antimicrobial consumption as Daily Defined Doses (DDD) or day of therapy (DOT) or percentage. A total of 19 studies measured antimicrobial consumption as DDDs or DOT. Meta-analysis revealed an overall high antimicrobial consumption of 68% (95% CI: 60% to 75%). The subgroup analysis found a lower consumption in high-income countries (58%, 95% CI: 48% to 67%), compared with lower and middle-income countries (89%, 95% CI: 82% to 94%). High antimicrobial consumption found in COVID-19 patients demands implementation of appropriate antimicrobial stewardship interventions.

"MuCovid-21" study: Mucormycosis at an Indian tertiary care centre during the COVID-19 pandemic

BACKGROUND

Mucormycosis has been reported in several Indian states with the second wave of COVID-19 from January 2021 onwards. This prospective study was conducted with the objective of defining the contribution or association of various known and many suspected factors in the incidence of this disease during the ongoing pandemic.

METHOD

The study included 464 adults with mucormycosis. Basic demographic data were collected. Patient history of COVID infection, its severity, duration of treatment, and oxygen use was taken to assess the association. History of use of antibiotics, steroids, antivirals, biologicals, and other complementary treatments was sought. History of diabetes and other comorbidities was noted. Patients were investigated for mucor confirmation using a nasal swab KOH mount, nasal endoscopy with biopsy, and radiological investigations were done to assess the extent.

RESULTS

Out of 464 patients, 175 were known diabetics, and 157 were treated with steroids during COVID infection. Out of 287 post-COVID patients, 125 (44%) had rhino-mucormycosis (RM), 102 (35%) had rhino-oculo-mucormycosis (ROM) and 60 (21%) had rhino-oculo-cerebral-mucormycosis (ROCM). 162 did not have a history of COVID, of which 93 (57%) had RM, 48 (30%) had ROM and 21 (13%) had ROCM.

CONCLUSION

This study has showed that COVID was not the only factor contributing to mucor, rather other factors such as diabetes, steroid use etc. were also contributory. Many patients who were suffering from mucormycosis did not have a history of COVID. Advanced age, ROCM, and ICU admission were associated with increased mortality.

Procalcitonin Increase Is Associated with the Development of Critical Care-Acquired Infections in COVID-19 ARDS

Secondary bacterial infection in COVID-19 patients is associated with increased mortality and disproportionately affects critically ill patients. This single-centre retrospective observational study investigates the comparative efficacy of change in procalcitonin (PCT) and other commonly available biomarkers in revealing or predicting microbiologically proven secondary infection in critical COVID-19 patients. Adult patients admitted to an intensive care unit (ICU) with confirmed SARS-CoV-2 infection between 9 March 2020 and 5 June 2020 were recruited to the study. For daily biomarker and secondary infection, laboratory-confirmed bloodstream infection (LCBI) and ventilator-associated pneumonia/tracheobronchitis (VAP/VAT) data were collected. We observed a PCT rise in 53 (81.5%) of the patients, a C-reactive protein (CRP) rise in 55 (84.6%) and a white blood cell count (WBC) rise in 61 (93.8%). Secondary infection was confirmed in 33 (50.8%) of the patients. A PCT rise was present in 97.0% of patients with at least one confirmed VAP/VAT and/or LCBI event. CRP and WBC rises occurred in 93.9% and 97.0% of patients with confirmed VAP/VAT and/or LCBI, respectively. Logistic regression analysis found that, when including all biomarkers in the same model, there was a significant association between PCT rise and the occurrence of LCBI and/or VAP/VAT (OR = 14.86 95%CI: 2.20, 342.53; p = 0.021). Conversely, no statistically significant relationship was found between either a CRP rise (p = 0.167) or a WBC rise (p = 0.855) and the occurrence of VAP/VAT and/or LCBI. These findings provide a promising insight into the usefulness of PCT measurement in predicting the emergence of secondary bacterial infection in ICU.

Co-infections and antimicrobial use among hospitalized COVID-19 patients in Punjab, Pakistan: findings from a multicenter, point prevalence survey

There are reports of high rates of antibiotic prescribing among hospitalized patients with COVID-19 around the world. To date, however, there are few reports of prescribing in relation to COVID-19 in Pakistan. Herein, we describe a point prevalence survey of antibiotic prescribing amongst patients hospitalized with suspected or proven COVID-19 in Pakistan. A Point Prevalence Survey (PPS) was undertaken in seven tertiary care health facilities in Punjab Provence, Pakistan. Baseline information about antimicrobial use according to the World Health Organization (WHO) standardized methodology was collected on a single day between 5^th and 30 April 2021. A total of 617 patients' records were reviewed and 578 (97.3%) were documented to be receiving an antibiotic on the day of the survey. The majority (84.9%) were COVID-19 PCR positive, 61.1% were male and 34.9% were age 36 to 44 years. One quarter presented with severe disease, and cardiovascular disease was the major comorbidity in 13%. Secondary bacterial infection or co-infection (bacterial infection concurrent with COVID-19) was identified in only 1.4%. On the day of the survey, a mean of 1.7 antibiotics was prescribed per patient and 85.4% antibiotics were recorded as being prescribed for 'prophylaxis'. The most frequently prescribed antibiotics were azithromycin (35.6%), ceftriaxone (32.9%) and meropenem (7.6%). The majority (96.3%) of the antibiotics were empirical and all were from WHO Watch or Reserve categories. Overall, a very high consumption of antibiotics in patients hospitalized with suspected or proven COVID-19 was observed in Pakistan and this is concerning in view of already high rates of antimicrobial resistance in the region. Antimicrobial stewardship programs need to urgently address unnecessary prescribing in the context of COVID-19 infection.

COVID-19 and antimicrobial stewardship: lessons learned, best practices, and future implications

The coronavirus disease 2019 (COVID-19) pandemic has had a profound and often devastating impact on global healthcare systems. Healthcare systems have had to repurpose programs and staff as part of COVID-19 relief efforts. The infrastructure and skilled personnel of antimicrobial stewardship programs (ASPs) have been utilized in new ways as part of COVID-19 pandemic response efforts. A critical focus of ASPs both before and during the pandemic has been on limiting the development of antimicrobial resistance. Fortunately, existing data indicate that rates of bacterial co-infection are relatively low and ASPs should continue aggressive efforts to limit unnecessary antimicrobial use. ASPs have taken a lead role in COVID-19 focused guideline creation and curation, as well as in helping to steward access to potential novel therapeutic agents. Disparities in ASP program resources and personnel exist, and ASP activities focused on the COVID-19 response should be tailored to individual settings. There is an urgent need for research to help inform ASP best practices within pandemic response efforts that take into account local resources. Investment in infrastructure and personnel is urgently needed both in the context of current relief efforts and to prepare for future pandemics.

COVID-19 and Antimicrobial Resistance: Data from the Greek Electronic System for the Surveillance of Antimicrobial Resistance-WHONET-Greece (January 2018-March 2021)

Changes in hospitals' daily practice due to COVID-19 pandemic may have an impact on antimicrobial resistance (AMR). We aimed to assess this possible impact as captured by the Greek Electronic System for the Surveillance of Antimicrobial Resistance (WHONET-Greece). Routine susceptibility data of 17,837 Gram-negative and Gram-positive bacterial isolates from blood and respiratory specimens of hospitalized patients in nine COVID-19 tertiary hospitals were used in order to identify potential differences in AMR trends in the last three years, divided into two periods, January 2018-March 2020 and April 2020-March 2021. Interrupted time-series analysis was used to evaluate differences in the trends of non-susceptibility before and after the changes due to COVID-19. We found significant differences in the slope of non-susceptibility trends of Acinetobacter baumannii blood and respiratory isolates to amikacin, tigecycline and colistin; of Klebsiella pneumoniae blood and respiratory isolates to meropenem and tigecycline; and of Pseudomonas aeruginosa respiratory isolates to imipenem, meropenem and levofloxacin. Additionally, we found significant differences in the slope of non-susceptibility trends of Staphylococcus aureus isolates to oxacillin and of Enterococcus faecium isolates to glycopeptides. Assessing in this early stage, through surveillance of routine laboratory data, the way a new global threat like COVID-19 could affect an already ongoing pandemic like AMR provides useful information for prompt action.