Key considerations on the potential impacts of the COVID-19 pandemic on antimicrobial resistance research and surveillance

Multiple impacts of the COVID-19 pandemic and antimicrobial stewardship on antimicrobial resistance in nosocomial infections: an interrupted time series analysis

Objectives

The emergency response to the COVID-19 pandemic may disrupt hospital management activities of antimicrobial resistance (AMR). This study aimed to determine the changing AMR trend over the period in China when stringent COVID-19 response measures were implemented.

Methods

This retrospective study was conducted in a designated hospital for COVID-19 patients in Guangzhou, China from April 2018 to September 2021. The prevalence of 13 antimicrobial-resistant bacteria was compared before and after the COVID-19 responses through Chi-square tests. Interrupted time series (ITS) models on the weekly prevalence of AMR were established to determine the changing trend. Controlled ITS models were performed to compare the differences between subgroups.

Results

A total of 10,134 isolates over 1,265 days were collected. And antimicrobial-resistant strains presented in 38.6% of the testing isolates. The weekly AMR prevalence decreased by 0.29 percentage point (95% CI [0.05-0.80]) after antimicrobial stewardship (AMS) policy, despite an increase in the prevalence of penicillin-resistant Streptococcus pneumoniae (from 0/43 to 15/43, p < 0.001), carbapenem-resistant Escherichia coli (from 20/1254 to 41/1184, p = 0.005), and carbapenem-resistant Klebsiella pneumoniae (from 93/889 to 114/828, p = 0.042). And the changing trend did not vary by gender (male vs. female), age (<65 vs. ≥65 years), service setting (outpatient vs. inpatient), care unit (ICU vs. non-ICU), the primary site of infection (Lung vs. others), and Gram type of bacteria (positive vs. negative).

Conclusion

The response to COVID-19 did not lead to an increase in overall AMR; however, it appears that management strategy on the prudent use of antimicrobials likely contributed to a sizable long-term drop. The frequency of several multidrug-resistant bacteria continues to increase after the COVID-19 epidemic. It is crucial to continue to monitor AMR when COVID-19 cases have surged in China after the relaxation of restriction measures.

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.

Perspectives of primary care physicians on academic detailing for antimicrobial stewardship: feasibility and impact assessment

OBJECTIVE

To understand primary care physicians' perspectives on academic detailing from an antimicrobial stewardship team to combat antibiotic overuse for upper respiratory infections and bronchitis in the COVID-19 era, which will help prevent avoidable outpatient visits.

METHODS

In this prospective study, 14 female Croatian physicians completed standardized qualitative interviews using a semi-structured guide. The data were analyzed using inductive methodology based on reflexive thematic analysis. We used a theoretically informed approach based on a conceptual framework of healthcare intervention implementability focused on three domains: acceptability, fidelity, and feasibility.

RESULTS

We identified six key themes highlighting barriers to changing prescribing practices, with patient pressure and specialist recommendations having an impact on the effectiveness of academic detailing. Despite challenges, primary care physicians described appreciation of direct interaction with evidence-based practices and reported usefulness, effectiveness, and further need for academic detailing.

CONCLUSION

This study highlights the complex dynamics involved in implementing healthcare interventions and provides valuable insights for enhancing strategies directed at improving antibiotic prescribing practices. Specifically, our findings emphasize factors influencing behavior changes in physicians' antibiotic prescribing. The authors advocate for a collaborative approach involving community and hospital-based professionals to provide tailored guidance and address questions, ultimately improving prescribing practices.

Outpatient antibiotic prescribing during the first two years of the COVID-19 pandemic: A nationwide register-based time series analysis

The COVID-19 pandemic has imposed an enormous burden on health care systems around the world. Simultaneously, many countries have reported a decrease in the incidence of other infectious diseases, such as acute respiratory infections, leading to a decline in outpatient antibiotic use. The aim of this study is to assess the impact of the COVID-19 pandemic on outpatient antibiotic prescribing in Finland during the first 2 years of the pandemic. We used nationwide register data, applied descriptive methods, and conducted an interrupted time series analysis (ITSA) using ARIMA modelling. Results from the ARIMA modelling showed that at the baseline, before the pandemic, the level of monthly number of antibiotic prescriptions was 248,560 (95% CI: 224,261 to 272,856; p<0.001) and there was a decreasing trend of 1,202 in monthly number of prescriptions (95% CI: -2,107 to -262; p<0.01). After the COVID-19 pandemic began, there was a statistically significant decline of 48,470 (95% CI: -76,404 to -20,535, p<0.001) prescriptions (-19.5% from the baseline level). The greatest decrease in antibiotic prescribing was observed among children aged 0-17 years. While antibiotic prescribing declined in all antibiotic groups associated with respiratory tract infections, the decrease from 2019 to 2020 was the largest with azithromycin (52.6%), amoxicillin (44.8%), and doxycycline (43.8%). Future studies should continue exploring antibiotic prescribing trends during the COVID-19 pandemic and beyond.

Impact of the COVID-19 pandemic on prevalence of highly resistant microorganisms in hospitalised patients in the Netherlands, March 2020 to August 2022

BackgroundThe COVID-19 pandemic resulted in adaptation in infection control measures, increased patient transfer, high occupancy of intensive cares, downscaling of non-urgent medical procedures and decreased travelling.AimTo gain insight in the influence of these changes on antimicrobial resistance (AMR) prevalence in the Netherlands, a country with a low AMR prevalence, we estimated changes in demographics and prevalence of six highly resistant microorganisms (HRMO) in hospitalised patients in the Netherlands during COVID-19 waves (March-June 2020, October 2020-June 2021, October 2021-May 2022 and June-August 2022) and interwaves (July-September 2020 and July-September 2021) compared with pre-COVID-19 (March 2019-February 2020).MethodsWe investigated data on routine bacteriology cultures of hospitalised patients, obtained from 37 clinical microbiological laboratories participating in the national AMR surveillance. Demographic characteristics and HRMO prevalence were calculated as proportions and rates per 10,000 hospital admissions.ResultsAlthough no significant persistent changes in HRMO prevalence were detected, some relevant non-significant patterns were recognised in intensive care units. Compared with pre-COVID-19 we found a tendency towards higher prevalence of meticillin-resistant Staphylococcus aureus during waves and lower prevalence of multidrug-resistant Pseudomonas aeruginosa during interwaves. Additionally, during the first three waves, we observed significantly higher proportions and rates of cultures with Enterococcus faecium (pooled 10% vs 6% and 240 vs 120 per 10,000 admissions) and coagulase-negative Staphylococci (pooled 21% vs 14% and 500 vs 252 per 10,000 admissions) compared with pre-COVID-19.ConclusionWe observed no substantial changes in HRMO prevalence in hospitalised patients during the COVID-19 pandemic.

Health systems appraisal of the response to antimicrobial resistance in low- and middle-income countries in relation to COVID-19: Application of the WHO building blocks

COVID-19 has inflicted both beneficial and damaging effects on health systems responding to antimicrobial resistance (AMR). Data shows that the positive impacts of the pandemic (including enhanced hygiene, mask wearing and widespread use of personal protective equipment), are likely to have been overshadowed by the negative effects: emerging AMR pathogens and mechanisms; further outbreaks and geographic spread of AMR to non-endemic countries; rising infections from multidrug-resistant pathogen; an overall higher burden of AMR. The multisectoral complexities of AMR and the totality of health systems challenge our ability to understand the impact of the COVID-19 pandemic on country responses to AMR. In this analysis, we synthesise international evidence characterising the role of the pandemic on the six key building blocks of health systems in responding to AMR across low- and middle-income countries (LMICs). We apply systems thinking within and between the building blocks to contextualise the impact of one pandemic on another.

Antibiotic use and consumption among medical patients of two hospitals in Sierra Leone: a descriptive report

BACKGROUND

Although one of the main drivers of antimicrobial resistance is inappropriate antibiotic prescribing, there are limited resources to support the surveillance of antibiotic consumption in low-income countries. In this study, we aimed to assess antibiotic use and consumption among medical patients of two hospitals in different geographic regions of Sierra Leone.

METHODS

This is a cross-sectional study of adult (18 years or older) patients receiving medical care at two hospitals (34 Military Hospital-MH and Makeni Government Hospital-MGH) between March 2021 and October 2021. After admission to the medical or intensive care unit, patients were sequentially recruited by a nurse from each hospital. Demographic and clinical characteristics and information on the dose of antibiotics, their routes, and frequency of administration and duration were collected using a questionnaire adapted from previous studies and encrypted in EpiCollect software (Epic, Verona WI). A physician reviews and verifies each completed questionnaire. Data analysis was done using STATA version 16.

RESULTS

The mean age of the 468 patients evaluated in this study was 48.6 years. The majority were women (241, 51.7%) and treated at MGH (245, 52.0%). Clinical diagnosis of bacterial infection was made in only 180 (38.5%) patients. Regardless of the diagnosis, most (442, 94.9%) patients received at least one antibiotic. Of a total 813 doses of antibiotics prescribed by the two hospitals, 424 (52.2%) were administered in MH. Overall, antibiotic consumption was 66.9 defined daily doses (DDDs) per 100 bed-days, with ceftriaxone being the most commonly used antibiotic (277, 34.1%). The ACCESS and WATCH antibiotics accounted for 18.9 DDDs per 100 bed-days (28.2%) and 48.0 DDDs per 100 bed-days (71.7%), respectively. None of the patients were prescribed a RESERVE antibiotics. The antibiotic consumption was lower in MH (61.3 DDDs per 100 bed-days) than MGH (76.5 DDDs per 100 bed-days).

CONCLUSION

Antibiotic consumption was highest with ceftriaxone, followed by levofloxacin and metronidazole. Given the high rate of consumption of antibiotics in the WATCH category of the AWaRe classification, there is a need to initiate surveillance of antibiotic consumption and establish hospital-based antibiotic stewardship in these settings.

The Impact of COVID-19 on Knowledge, Beliefs, and Practices of Ni-Vanuatu Health Workers Regarding Antibiotic Prescribing and Antibiotic Resistance, 2018 and 2022: A Mixed Methods Study

Antimicrobial resistance (AMR) is included in the ten most urgent global public health threats. Global evidence suggests that antibiotics were over prescribed during the early waves of the COVID-19 pandemic, particularly in low- and middle-income countries. Inappropriate use of antibiotics drives the emergence and spread of antibiotic resistance. This study aimed to examine the impact of COVID-19 on Ni-Vanuatu health worker knowledge, beliefs, and practices (KBP) regarding antibiotic prescribing and awareness of antibacterial AMR. A mixed methods study was conducted using questionnaires and in-depth interviews in 2018 and 2022. A total of 49 respondents completed both baseline (2018) and follow-up (2022) questionnaires. Knowledge scores about prescribing improved between surveys, although health workers were less confident about some prescribing activities. Respondents identified barriers to optimal hand hygiene performance. More than three-quarters of respondents reported that COVID-19 influenced their prescribing practice and heightened their awareness of ABR: "more careful", "more aware", "stricter", and "need more community awareness". Recommendations include providing ongoing continuing professional development to improve knowledge, enhance skills, and maintain prescribing competency; formalising antibiotic stewardship and infection, prevention, and control (IPC) programmes to optimise prescribing and IPC practices; and raising community awareness about ABR to support more effective use of medications.

Stakeholders' perception of factors influencing adoption of a pediatric weight management intervention: a qualitative study

Background

Childhood obesity is highly prevalent in the United States and disproportionately impacts communities of color and low-income populations; these disparities have worsened during the COVID-19 pandemic. Adoption of effective pediatric weight management interventions (PWMIs) that have been evaluated among low-income diverse populations is needed. The Healthy Weight Clinic PWMI, a package co-developed by the American Academy of Pediatrics and Massachusetts General Hospital, helps health centers establish multidisciplinary Healthy Weight Clinics based on previous randomized controlled trials which demonstrated effectiveness. We sought to identify the factors influencing successful adoption of this PWMI and understand adaptations needed prior to implementation in new sites.

Methods

We interviewed 20 stakeholders, 10 from two health centers in Mississippi where the Healthy Weight Clinic PWMI will be piloted (pre-implementation sites) and 10 from health centers that have previously implemented it (sites in maintenance stages). Separate interview guides informed by the Consolidated Framework for Implementation Research (CFIR) were developed for the pre-implementation sites and those in maintenance stages, including questions related to adaptations of the PWMI in response to the COVID-19 pandemic. Qualitative data analysis was conducted using directed content analysis based on CFIR constructs. Adaptations in response to the pandemic were categorized using Framework for Reporting Adaptations and Modifications-Expanded (FRAME).

Results

In pre-implementation sites, an inner setting facilitator mentioned was a positive learning climate. Characteristics of individuals that can facilitate adoption include staff willingness to learn, valuing evidence-based care for childhood obesity, and culturally and weight-sensitive staff. In terms of patient needs and resources (outer setting), social drivers of health are barriers to adoption, but creative solutions were suggested to mitigate these. Other facilitators related to the intervention included its multidisciplinary model and adaptability. Similar themes were elicited from sites in maintenance stages; adaptations brought on by the pandemic, such as telehealth visits and content modification to align with distancing guidelines and the effects of social isolation were also described.

Conclusion

Understanding the factors influencing adoption of an evidence-based PWMI informs necessary adaptations and implementation strategies required to facilitate nationwide dissemination of PWMIs, with the goal of reaching the populations most at-risk.

The impact of the COVID-19 pandemic on the treatment of common infections in primary care and the change to antibiotic prescribing in England

BACKGROUND

There is concern that the COVID-19 pandemic altered the management of common infections in primary care. This study aimed to evaluate infection-coded consultation rates and antibiotic use during the pandemic and how any change may have affected clinical outcomes.

METHODS

With the approval of NHS England, a retrospective cohort study using the OpenSAFELY platform analysed routinely collected electronic health data from GP practices in England between January 2019 and December 2021. Infection coded consultations and antibiotic prescriptions were used estimate multiple measures over calendar months, including age-sex adjusted prescribing rates, prescribing by infection and antibiotic type, infection consultation rates, coding quality and rate of same-day antibiotic prescribing for COVID-19 infections. Interrupted time series (ITS) estimated the effect of COVID-19 pandemic on infection-coded consultation rates. The impact of the pandemic on non- COVID-19 infection-related hospitalisations was also estimated.

RESULTS

Records from 24 million patients were included. The rate of infection-related consultations fell for all infections (mean reduction of 39% in 2020 compared to 2019 mean rate), except for UTI which remained stable. Modelling infection-related consultation rates highlighted this with an incidence rate ratio of 0.44 (95% CI 0.36-0.53) for incident consultations and 0.43 (95% CI 0.33-0.54) for prevalent consultations. Lower respiratory tract infections (LRTI) saw the largest reduction of 0.11 (95% CI 0.07-0.17). Antibiotic prescribing rates fell with a mean reduction of 118.4 items per 1000 patients in 2020, returning to pre-pandemic rates by summer 2021. Prescribing for LRTI decreased 20% and URTI increased 15.9%. Over 60% of antibiotics were issued without an associated same-day infection code, which increased during the pandemic. Infection-related hospitalisations reduced (by 62%), with the largest reduction observed for pneumonia infections (72.9%). Same-day antibiotic prescribing for COVID-19 infection increased from 1 to 10.5% between the second and third national lockdowns and rose again during 2022.

CONCLUSIONS

Changes to consultations and hospital admissions may be driven by reduced transmission of non-COVID-19 infections due to reduced social mixing and lockdowns. Inconsistencies in coding practice emphasises the need for improvement to inform new antibiotic stewardship policies and prevent resistance to novel infections.

Characterization of consumption and costs of antimicrobials in intensive care units in a Brazilian tertiary hospital

Background

The consumption of antimicrobials and the growing resistance of infectious agents to these drugs are not related only to health issues, but also to economic parameters.

Objectives

The study objective was to evaluate the consumption of antimicrobials in General and Covid-19 Intensive Care Units (ICUs) and the impact on institutional costs in the largest institute of a tertiary public hospital.

Methods

This is a quantitative and retrospective study, which analyzed consumption, through the Defined Daily Dose (DDD), and the annual direct cost of antimicrobials in Reais (R$) and Dollars (US$), from January to December 2021.

Results

The total annual consumption (DDD/1000 patient-day) of antimicrobials in the ICUs was 14,368.85. β-Lactams had the highest total annual value, with a DDD/1000 patient-day of 7062.98, being meropenem the antimicrobial that reached the highest consumption (3107.20), followed by vancomycin (2322.6). Total consumption was higher in Covid-19 ICUs than in General ICUs, and the annual direct cost of antimicrobials in ICUs was US$560,680.79.

Conclusions

The study showed high consumption of broad-spectrum antimicrobials, highlighting the importance of structuring programs to manage the use of antimicrobials, both to reduce antimicrobial consumption and hospital costs, consolidating rational use even in pandemic scenarios.

Antibiotics Prescriptions Pattern among Patients Visiting Primary Health Care Centers (PHCC) before and during COVID-19 Pandemic: A Cross-Sectional Population-Based Study from Qatar

BACKGROUND

The COVID-19 pandemic, caused by the novel coronavirus 2 (SARS-CoV-2), has been associated with an increased risk of secondary bacterial infections. Numerous studies have reported a surge in antibiotic usage during the COVID-19 pandemic. This study aims to examine the impact of the COVID-19 pandemic on the frequency and patterns of antibiotic prescriptions at Primary Health Care Centers (PHCC) in Qatar, comparing the period before and during the pandemic.

METHODS

This population-based, cross-sectional study analyzed all antibiotic prescriptions issued in two-month intervals before COVID-19 (November and December 2019) and during the initial wave (June and July 2020) of COVID-19. The study included 27 PHCCs in Qatar.

RESULTS

Prior to the COVID-19 outbreak, the PHCCs dispensed a total of 74,909 antibiotic prescriptions in November and December. During the first wave of COVID-19, the number decreased to 29,273 prescriptions in June and July 2020. Antibiotics were most commonly prescribed for adults and least commonly for the elderly, both before and during the COVID-19 period. In the pre-COVID-19 period, Betalactams and macrolides accounted for the majority (73%) of all antibiotic prescriptions across all age groups. However, during the COVID-19 period, Betalactams and other antibiotics such as Nitrofurantoin and Metronidazole (73%) were the most frequently prescribed.

CONCLUSION

The rate of antibiotic prescriptions during the first wave of COVID-19 was lower compared to the two months preceding the pandemic at the PHCC in Qatar.

Clinical and Economic Value of Reducing Antimicrobial Resistance in the Management of Hospital-Acquired Infections with Limited Treatment Options in Greece

INTRODUCTION

Antimicrobial resistance (AMR) is a major public health threat worldwide. Greece has the highest burden of infections due to antibiotic-resistant bacteria among European Union/European Economic Area (EU/EEA) countries. One of the most serious AMR threats in Greece is hospital-acquired infections (HAIs) with limited treatment options (LTO) caused by resistant gram-negative pathogens. Thus, this study sought to estimate the current AMR burden in Greece and the value of reducing AMR to gram-negative pathogens for the Greek healthcare system.

METHODS

The current model was adapted from a previously published and validated model of AMR to investigate the overall and AMR-specific burden of treating the most common HAIs with LTO in Greece and scenarios to demonstrate the benefits associated with reducing AMR levels from a third-party payer perspective. Clinical and economic outcomes were estimated over a 10-year time horizon; life years (LYs) and quality-adjusted life years (QALYs) were calculated over a lifetime (based on the annual number of infections over 10 years) at a willingness-to-pay of €30,000 per QALY gained and a 3.5% discount rate.

RESULTS

In Greece, the current AMR levels in HAIs with LTO caused by four gram-negative pathogens account for > 316,000 hospital bed days, €73 million in hospitalisation costs, and > 580,000 LYs and 450,000 QALYs lost over 10 years. The monetary burden is estimated at €13.9 billion. A reduction in current AMR levels by 10-50% results in clinical and economic benefit; 29,264-151,699 bed days may be saved, leading to decreased hospitalisation costs (€6.8 million-€35.3 million) and a gain in LYs (85,328-366,162) and QALYs (67,421-289,331), associated with a monetary benefit of between €2.0 billion and €8.7 billion.

CONCLUSION

This study shows the substantial clinical and economic burden AMR represents to the Greek healthcare system and the value that can be achieved by effectively reducing AMR levels.

The Impact of the COVID-19 Pandemic on Antimicrobial Resistance and Management of Bloodstream Infections

INTRODUCTION

The pressure of the COVID-19 pandemic on healthcare systems led to limited roles of infectious diseases services, increased rates of irrational use of antimicrobials, and incidence of infections by multidrug-resistant microorganisms. The aim of the present study is to evaluate the incidence of antimicrobial resistance and the management of bloodstream infections before and during the COVID-19 pandemic at the University General Hospital of Alexandroupolis (Greece).

MATERIALS AND METHODS

This is a retrospective study conducted from January 2018 to December 2022. Data were collected from the University Microbiology Laboratory per semester regarding the isolated strains of Gram-positive and -negative bacteria in blood cultures and respiratory samples in hospitalized patients in medical and surgical wards and in the intensive care unit (ICU). Additionally, bloodstream infections with requested infectious disease consultations were reported (n = 400), determining whether these were carried out via telephone contact or at the patient's bedside. Demographic data, comorbidities, focus of infection, antimicrobial regimen, duration of treatment, length of hospitalization, and clinical outcome were analyzed.

RESULTS

A total of 4569 strains of Gram-positive and -negative bacteria were isolated. An increasing trend was reported compared to the pre-pandemic period in the incidence of resistant Gram-negative bacteria, particularly in ICUs. Prior antimicrobial use and the rate of hospital-acquired infections were increased significantly during the pandemic. In the pre-pandemic period 2018-2019, a total of 246 infectious disease consultations were carried out, while during the period 2020-2022, the number was 154, with the percentage of telephone consultations 15% and 76%, respectively. Detection of the source of infection and timely administration of appropriate antimicrobial agents were more frequently recorded before the pandemic, and 28-day mortality was significantly reduced in cases with bedside consultations.

CONCLUSION

The empowering of infectious disease surveillance programs and committees, rational use of antimicrobials agents, and bedside infectious disease consultations are vital in order to reduce the impact of infections caused by multidrug-resistant strains.

Antibiotic resistance and consumption before and during the COVID-19 pandemic in Valle del Cauca, Colombia

Objective

To assess changes in antibiotic resistance of eight of the World Health Organization priority bug-drug combinations and consumption of six antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ciprofloxacin, vancomycin) before (March 2018 to July 2019) and during (March 2020 to July 2021) the COVID-19 pandemic in 31 hospitals in Valle del Cauca, Colombia.

Methods

This was a before/after study using routinely collected data. For antibiotic consumption, daily defined doses (DDD) per 100 bed-days were compared.

Results

There were 23 405 priority bacterial isolates with data on antibiotic resistance. The total number of isolates increased from 9 774 to 13 631 in the periods before and during the pandemic, respectively. While resistance significantly decreased for four selected bug-drug combinations (Klebsiella pneumoniae, extended spectrum beta lactamase [ESBL]-producing, 32% to 24%; K. pneumoniae, carbapenem-resistant, 4% to 2%; Pseudomonas aeruginosa, carbapenem-resistant, 12% to 8%; Acinetobacter baumannii, carbapenem-resistant, 23% to 9%), the level of resistance for Enterococcus faecium to vancomycin significantly increased (42% to 57%). There was no change in resistance for the remaining three combinations (Staphylococcus aureus, methicillin-resistant; Escherichia coli, ESBL-producing; E. coli, carbapenem-resistant). Consumption of all antibiotics increased. However, meropenem consumption decreased in intensive care unit settings (8.2 to 7.1 DDD per 100 bed-days).

Conclusions

While the consumption of antibiotics increased, a decrease in antibiotic resistance of four bug-drug combinations was observed during the pandemic. This was possibly due to an increase in community-acquired infections. Increasing resistance of E. faecium to vancomycin must be monitored. The findings of this study are essential to inform stewardship programs in hospital settings of Colombia and similar contexts elsewhere.

Flare of the silent pandemic in the era of the COVID-19 pandemic: Obstacles and opportunities

A noteworthy public health problem, antimicrobial resistance (AMR) has been impeded in many ways by the coronavirus disease 2019 (COVID-19) pandemic. This narrative review discusses the two-sided impact of COVID-19 on the magnitude of AMR. The pandemic has put tremendous strain on healthcare systems, diverting resources, personnel, and attention away from AMR diagnosis and management toward COVID-19 diagnosis and contact tracking and tracing. AMR research has been severely hampered, and surveillance and antimicrobial stewardship (AMS) programs have been de-emphasized, delayed, or halted. Antibiotics, particularly broad-spectrum, were prescribed more frequently without diagnostic confirmation of bacterial infection than before the pandemic. Nonetheless, the COVID-19 pandemic has highlighted the vulnerability of healthcare systems in controlling infectious disease threats and raised awareness of the importance of infection prevention and control. Yet, the pandemic has created opportunities to capitalize on positive effects on AMR management. The review concludes that it is now more important than ever to focus on AMR and strengthen AMS programs to ensure appropriate antibiotic use and other AMR prevention measures in healthcare. We must ensure that one of the COVID-19 legacies is increased support for AMR research, diagnostic implementation, appropriate diagnostic stewardship, and the strengthening of our health systems. The COVID-19 pandemic has demonstrated that prevention is better than cure. Countries will need to step up their efforts to combat AMR as a multidisciplinary community. We must prepare our public health systems to combat multiple threats at the same time.

Impact of COVID-19 Pandemic in Antibiotic Consumption in Navarre (Spain): An Interrupted Time Series Analysis

On 11 March 2020, the World Health Organization declared coronavirus disease 19 (COVID-19) a global pandemic. This exceptional situation changed the world not only in terms of mortality and morbidity, but also in terms of epidemiology and health system resources consumption. The objective of this work was to analyze the consumption of antibiotics during the period around the pandemic in our region. A drug utilization study was performed comparing the antibiotic consumption in the community during the years 2018, 2019, 2020, and 2021. Quarterly antibiotic use (defined daily doses (DDD) per 1000 inhabitants per day (DID)) and number of patients treated were the outcomes. Interrupted time series regression analysis was performed to estimate the statistical significance of the change in level of consumption before and after the COVID-19 pandemic. The drop of global antibiotic consumption was statistically significant, both in number of patients and in DID when analyzing pre-pandemic period versus pandemic period. The use of strategic antibiotics for respiratory infections such as amoxicillin, amoxicillin-clavulanic acid, and levofloxacin also decreased significantly. Seasonal pattern of use of antibiotics disappeared due to the global measures imposed over the world to work against COVID-19.

Hospital Antibiotic Use during COVID-19 Pandemic in Italy

Antimicrobial resistance (AMR) represents a major issue in healthcare being correlated to global inappropriate use of antibiotics. The aim of this study was to compare the data on hospital antibiotic consumption in 2020-2021 with those related to 2019 in order to evaluate the impact of the COVID-19 pandemic on antibiotic prescriptions and appropriate use at national level and in the different geographical areas. To estimate the consumption of antibiotics, two indicators were calculated: "number of DDD per 1000 inhabitants per day" and "number of DDD per 100 hospitalisation days". Consumption data on antibiotics dispensed in public health facilities were based on the Italian "traceability of medicines" information flow. Data on hospitalisation days were extracted from the Italian "hospital discharge form" flow. Pearson correlation analysis was performed between the number of patients hospitalised for COVID-19 and the consumption of antibiotics in public healthcare facilities. During 2020, about 1.7 DDD/1000 inhabitants per day (12.3% of the overall consumption of reimbursed antibiotics) were dispensed exclusively in Italian hospitals (+0.8% compared to 2019). Considering the number of DDD per 100 hospitalisation days, consumption increased by 19.3% in 2020 compared to 2019. Comparing the first semester of 2020 and 2019, a decrease of DDD/1000 inhabitants per day was observed (-1.6%) at national level, with opposite trends in the different geographical areas; an increase in the use of azithromycin and carbapenems was also observed, with a stable consumption of third-generation cephalosporins. The use of antibiotics in the second semester of 2020 compared to the same period of 2019 showed a clear reduction at national level (-8.5%), appreciable to a similar extent in all geographic areas. In the first semester of 2021 compared to the same period of 2020, there was a huge reduction (-31.4%) in consumption at national level. However, the variations were heterogeneous between different geographical areas. To our knowledge, this study represents the most comprehensive analysis performed on antibiotic consumption data in hospital settings in Italy during the COVID-19 pandemic to date. Despite international and national guideline recommendations, a substantial overall increase in antibiotic prescriptions was observed during the COVID-19 pandemic, with variability in terms of geographical distribution and prescription strategies. These findings may be related to the dichotomy between perceived and real significance of guidelines, expert panels, or consensus. Therefore, new approaches or strategies to antimicrobial stewardship should be proposed.

The Role of COVID-19 in Antibiotic Resistance in Pediatric Population

There is data on the irrational use of antimicrobial drugs in pediatric population during the COVID-19 pandemic. This could lead to potential development of antibiotic resistance and increased morbidity and mortality among this vulnerable population group. The aim of this review is to study the role of COVID-19 in antimicrobial drugs administration and antibiotic resistance development, as well as to determine a set of measures for its prevention. Recent studies results have shown that COVID-19 pandemic had both direct and indirect impact on antibiotic resistance development in pediatric population. The COVID-19 outbreak has revealed weaknesses in health systems around the world. Antibiotics administration in patients with coronavirus infection during this period exceeded the number of cases with bacterial co-infection or other diseases. Thus, it indicates irrational antibiotic treatment. There were cases of inappropriate antibiotics administration during the crisis caused by the COVID-19 pandemic even in regions with long-term rational antibiotic treatment programs. One of the most viable methods to combat antibiotic resistance is to improve approaches in health care and to increase preparedness to infectious outbreaks. Increasing clinical competence of medical workers, accessibility of medical facilities, permanent supply of high-quality and cheap antibiotics, vaccines, reducing COVID-19 testing time, and adequate administration of antibacterial agents are the measures that can prevent diseases caused by drug resistance. All stakeholders (health authorities, regulating authorities, politicians, scientific community, pharmaceutical companies) have to collaborate and achieve results to implement all the mentioned above protection measures.

Impact of coronavirus disease 2019 (COVID-19) pandemic in hospital-acquired infections and bacterial resistance at an oncology hospital

Objective

Hospital-acquired infection (HAI) rates were negatively affected by the the coronavirus disease 2019 (COVID-19) pandemic. We describe the incidence of HAIs, main pathogens, and multidrug-resistant organisms (MDROs) isolated in cancer patients before and during the pandemic.

Design

This retrospective, comparative study included patients with HAIs. We compared 2 periods: the prepandemic period (2018, 2019, and the first 3 months of 2020) with the pandemic period (April-December 2020 and all of 2021).

Setting

Instituto Nacional de Cancerología, a tertiary-care oncology public hospital in Mexico City, Mexico.

Methods

Patients with the following HAIs were included: nosocomial pneumonia, ventilator-associated pneumonia (VAP), secondary bloodstream infection (BSI), central-line-associated bloodstream infection (CLBSI), and Clostridioides difficile infection (CDI). Demographic data, clinical characteristics, pathogens isolated, and MDRO data were included.

Results

We identified 639 HAIs: 381 (7.95 per 100 hospital discharges) in the prepandemic period and 258 (7.17 per 100 hospital discharges) in the pandemic period. Hematologic malignancy was documented in 263 (44.3%) patients; 251 (39.2%) were in cancer progression or relapse. Nosocomial pneumonia was more frequent during the pandemic period (40.3% vs 32.3%; P = .04). Total episodes of VAP were not different between the 2 periods (28.1% vs 22.1%; P = .08), but during the pandemic period, the VAP rate was higher among COVID-19 patients than non-COVID-19 patients (72.2% vs 8.8%; P < .001). Escherichia coli, Stenotrophomonas maltophilia, and Staphylococcus aureus bacteremia cases were more frequent in the pandemic period. Extended-spectrum β-lactamases (ESBL)-E. coli was the only MDRO that occurred more frequently during the pandemic period.

Conclusions

In cancer patients, nosocomial pneumonia was more frequent during the pandemic period. We did not observe a significant impact on other HAIs. MDROs did not significantly increase during the pandemic.

Antibiotic consumption in secondary and tertiary hospitals in Colombia: national surveillance from 2018-2020

Objective

To assess the compliance in secondary and tertiary level hospitals with monthly reporting of antibiotic consumption to the Colombian National Public Health Surveillance System (SIVIGILA-INS), and to describe reported antibiotic consumption during 2018-2020.

Methods

This study involved a secondary analysis of antibiotic consumption data reported to SIVIGILA-INS. Frequency of hospital reporting was assessed and compared against expected reports, disaggregated by intensive care units (ICU)/non-ICU wards and geographical regions. Consumption was expressed as defined daily dose (DDD) per 100 occupied beds for seven antibiotics.

Results

More than 70% of hospitals reported antibiotic consumption at least once in each of the three years (79% in ICU and 71% in non-ICU wards). Of these, ICU monthly reporting was complete (12 monthly reports per year) for 59% in the period 2018-2019 but only 4% in 2020. Non-ICU reporting was complete for 52% in 2019 and for 2% in 2020. Most regions had an overall decrease in reporting in 2020. Analysis of antibiotic consumption showed an increase for piperacillin/tazobactam, ertapenem, and cefepime from 2019 to 2020.

Conclusions

There were gaps in the consistency and frequency of reporting. Efforts are needed to improve compliance with monthly reporting, which declined in 2020, possibly due to the COVID-19 pandemic. Non-compliance on reporting and data quality issues should be addressed with the hospitals to enable valid interpretation of antibiotic consumption trends.

Risk stratification for selecting empiric antibiotherapy during and after COVID-19

PURPOSE OF REVIEW

SARS-CoV-2 deeply modified the risk of bacterial infection, bacterial resistance, and antibiotic strategies. This review summarized what we have learned.

RECENT FINDINGS

During the COVID-19 pandemic, we observed an increase in healthcare-acquired infection and multidrug-resistant organism-related infection, triggered by several factors: structural factors, such as increased workload and ongoing outbreaks, underlying illnesses, invasive procedures, and treatment-induced immunosuppression. The two most frequently healthcare-acquired infections described in patients hospitalized with COVID-19 were bloodstream infection, related or not to catheters, health-acquired pneumonia (in ventilated or nonventilated patients). The most frequent species involved in bacteremia were Gram-positive cocci and Gram-negative bacilli in health-acquired pneumonia. The rate of Gram-negative bacilli is particularly high in late-onset ventilator-associated pneumonia, and the specific risk of Pseudomonas aeruginosa- related pneumonia increased when the duration of ventilation was longer than 7 days. A specificity that remains unexplained so far is the increase in enterococci bacteremia.

SUMMARY

The choice of empiric antibiotimicrobials depends on several factors such as the site of the infection, time of onset and previous length of stay, previous antibiotic therapy, and known multidrug-resistant organism colonization. Pharmacokinetics of antimicrobials could be markedly altered during SARS-CoV-2 acute respiratory failure, which should encourage to perform therapeutic drug monitoring.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital

Background

There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital.

Methods

We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time.

Results

Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016–1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96).

Conclusions

In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01114-x.

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.

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 5th 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.

Rhodococcus strains as a good biotool for neutralizing pharmaceutical pollutants and obtaining therapeutically valuable products: Through the past into the future

Active pharmaceutical ingredients present a substantial risk when they reach the environment and drinking water sources. As a new type of dangerous pollutants with high chemical resistance and pronounced biological effects, they accumulate everywhere, often in significant concentrations (μg/L) in ecological environments, food chains, organs of farm animals and humans, and cause an intense response from the aquatic and soil microbiota. Rhodococcus spp. (Actinomycetia class), which occupy a dominant position in polluted ecosystems, stand out among other microorganisms with the greatest variety of degradable pollutants and participate in natural attenuation, are considered as active agents with high transforming and degrading impacts on pharmaceutical compounds. Many representatives of rhodococci are promising as unique sources of specific transforming enzymes, quorum quenching tools, natural products and novel antimicrobials, biosurfactants and nanostructures. The review presents the latest knowledge and current trends regarding the use of Rhodococcus spp. in the processes of pharmaceutical pollutants’ biodegradation, as well as in the fields of biocatalysis and biotechnology for the production of targeted pharmaceutical products. The current literature sources presented in the review can be helpful in future research programs aimed at promoting Rhodococcus spp. as potential biodegraders and biotransformers to control pharmaceutical pollution in the environment.

Changes in Group B Streptococcus Colonization among Pregnant Women before and after the Onset of the COVID-19 Pandemic in Brazil

Group B Streptococcus (GBS) is a leading cause of neonatal infections. The genitourinary and gastrointestinal tract of pregnant women are the main source of transmission to newborns. This work investigated the prevalence and characterized GBS from pregnant women in Rio de Janeiro, Brazil, comparing the periods before (January 2019 to March 2020; 521) and during (May 2020 to March 2021; 285) the COVID-19 pandemic. GBS was detected in 10.8% of anovaginal samples. Considering scenarios before and during the pandemic, GBS colonization rate significantly decreased (13.8% vs. 5.3%; p = 0.0001). No clinical and sociodemographic aspect was associated with GBS carriage (p > 0.05). A total of 80%, 13.8% and 4.6% GBS strains were non-susceptible to tetracycline, erythromycin and clindamycin, respectively. Serotype Ia was the most frequent (47.7%), followed by V (23.1%), II (18.4%), III (7.7%) and Ib (3.1%). An increasing trend of serotypes Ib and V, as well as of antimicrobial resistance rates, and a decreasing trend of serotypes II and III, were observed after the pandemic onset, albeit not statistically significant (p > 0.05). The reduction in GBS colonization rates and alterations in GBS serotypes and resistance profiles during the pandemic were not due to changes in the sociodemographic profile of the population. Considering that control and preventive measures related to the COVID-19 pandemic onset have impacted other infectious diseases, these results shed light on the need for the continuous surveillance of GBS among pregnant women in the post-pandemic era.

Bacterial co-infections and antimicrobial resistance associated with the Coronavirus Disease 2019 infection

Bacterial co-infections are typically associated with viral respiratory tract infections and pose a significant public health problem around the world. COVID-19 infection damages tissues lining the respiratory track and regulates immune cells/cytokines leading to microbiome dysbiosis and facilitating the area to be colonized by pathogenic bacterial agents. There have been reports of different types of bacterial co-infection in COVID-19 patients. Some of these reports showed despite geographical differences and differences in hospital settings, bacterial co-infections are a major cause of morbidity and mortality in COVID-19 patients. The inappropriate use of antibiotics for bacterial infections, particularly broad-spectrum antibiotics, can also further complicate the infection process, often leading to multi drug resistance, clinical deterioration, poor prognosis, and eventually death. To this end, researchers must establish a new therapeutic approach to control SARS-CoV-2 and the associated microbial coinfections. Hence, the aim of this review is to highlight the bacterial co-infection that has been recorded in COVID-19 patients and the status of antimicrobial resistance associated with the dual infections.

Seleno-Metabolites and Their Precursors: A New Dawn for Several Illnesses?

Selenium (Se) is an essential element for human health as it is involved in different physiological functions. Moreover, a great number of Se compounds can be considered potential agents in the prevention and treatment of some diseases. It is widely recognized that Se activity is related to multiple factors, such as its chemical form, dose, and its metabolism. The understanding of its complex biochemistry is necessary as it has been demonstrated that the metabolites of the Se molecules used to be the ones that exert the biological activity. Therefore, the aim of this review is to summarize the recent information about its most remarkable metabolites of acknowledged biological effects: hydrogen selenide (HSe-/H2Se) and methylselenol (CH3SeH). In addition, special attention is paid to the main seleno-containing precursors of these derivatives and their role in different pathologies.

Curbing antimicrobial resistance in post-COVID Africa: Challenges, actions and recommendations

Background

Antimicrobial self-medication and use have significantly increased in the COVID-19 era-increasing antibiotic consumption and resulting in a high prevalence of antimicrobial resistance in Africa (AMR). We conducted a narrative review to investigate challenges associated with curbing AMR in a post-COVID-19 setting in Africa, suggesting practical measures applicable for policy-informed implementation.

Method

A narrative review was performed to pinpoint AMR challenges and actions on the African continent. A comprehensive search was conducted in the scientific databases that include PubMed, PubMed Central and Google Scholar using predetermined search terms.

Results

The emergence of the COVID-19 outbreak has added to the challenges of tackling AMR on the continent, which has jeopardized AMR interventions' hard-won gains. Identified challenges have been Health systems disruption, Irrational Antimicrobial Use, Weak Antimicrobials Regulatory Ecosystem, Inefficient Population Infection Prevention, and Control Practices, Inadequate access to Health Services and data challenge on AMR surveillance.

Conclusion

The COVID-19 pandemic fueled AMR in Africa. There is a need for AMR control post-COVID, such as measures for ongoing antimicrobial stewardship and good infection control practices. Further, curbing AMR requires rigorous regulatory enforcement and efficient AMR Surveillance. There should be a body to raise AMR awareness among the population. Research, Innovation and Technology could play an essential role supported by capacity building and global partnership.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: −0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: −0.8, p < 0.001); and doxycycline (−0.2, p = 0.005) and penicillin (−0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

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.

Stemming the Rise of Antibiotic Use for Community-Acquired Acute Respiratory Infections during COVID-19 Pandemic

At the start of the COVID-19 pandemic, there was an increase in the use of antibiotics for the treatment of community-acquired respiratory tract infection (CA-ARI) in patients admitted for suspected or confirmed COVID-19, raising concerns for misuse. These antibiotics are not under the usual purview of the antimicrobial stewardship unit (ASU). Serum procalcitonin, a biomarker to distinguish viral from bacterial infections, can be used to guide antibiotic recommendations in suspected lower respiratory tract infection. We modified our stewardship approach, and used a procalcitonin-guided strategy to identify “high yield” interventions for audits in patients admitted with CA-ARI. With this approach, there was an increase in the proportion of patients with antibiotics discontinued within 4 days (16.5% vs. 34.9%, p < 0.001), and the overall duration of antibiotic therapy was significantly shorter [7 (6−8) vs. 6 (3−8) days, p < 0.001]. There was a significant decrease in patients with intravenous-to-oral switch of antibiotics to “complete the course” (45.3% vs. 34.4%, p < 0.05). Of the patients who had antibiotics discontinued, none were restarted on antibiotics within 48 h, and there was no-30-day readmission or 30-day mortality attributed to respiratory infection. This study illustrates the importance of the antimicrobial stewardship during the pandemic and the need for ASU to remain attuned to prescriber’s practices, and adapt accordingly to address antibiotic misuse to curb antimicrobial resistance.

Antimicrobial Resistance Research Collaborations in Asia: Challenges and Opportunities to Equitable Partnerships

Antimicrobial Resistance is recognized as a major threat to global health security. The WHO Southeast Asia region is dubbed a “global hub for AMR emergence”, as it runs the highest risk for AMR emergence among all WHO regions in Asia. Hence, there is a need for Asia-centric, collaborative AMR research aligned with the true needs and priorities of the region. This study aimed to identify and understand the challenges and opportunities for such collaborative endeavors to enhance equitable partnerships. This qualitative study adopted an interpretative approach involving a thematic analysis of 15 semi-structured interviews with AMR experts conducting research in the region. The study identified several factors influencing research collaborations, such as the multi-dimensional nature of AMR, limited or lack of funds, different AMR research priorities in Asian countries, absence of Asia-centric AMR leadership, lack of trust and, unequal power relationships between researchers, and the negative impact of the COVID-19 pandemic in research collaborations. It also identified some opportunities, such as the willingness of researchers to collaborate, the formation of a few networks, and the prioritization by many academics of the One Health paradigm for framing AMR research. Participants reported that the initiation of stronger cross-discipline and cross-country networks, the development of Asia-centric AMR leadership, flexible research agendas with shared priorities, transparent and transferable funds, and support to enhance research capacity in LMICs could assist in developing more equitable collaborative research in Asia.

Evaluation of Antibacterial and Antiviral Drug Effectiveness in COVID-19 Therapy: A Data-Driven Retrospective Approach

The clinical manifestations associated with COVID-19 disease is mainly due to a dysregulated host response related to the overexpression of inflammatory markers. Until recently, only remdesivir had gained FDA approval for COVID-19 hospitalized patients and there are currently no evidence-based therapeutic options or options for prevention of complications that have been established. Some medical treatments such as antivirals, antibacterials, antithrombotics, antipyretics, corticosteroids, interleukin inhibitors, monoclonal antibodies, convalescent plasma, immunostimulants, and vitamin supplements have been utilized. However, there are limited data to support their effectiveness. Hence, this study was attempted to identify and evaluate the effectiveness of antibacterials and antivirals used for COVID-19 using a retrospective cross-sectional approach based on the medical records of adult patients in four hospitals. The number of antibacterials was calculated in defined daily dose (DDD) per 100 bed-days unit. Both mixed-logit regression and analysis of covariance were used to determine the effectiveness of the aforementioned agents in relation to COVID-19 outcome and patients' length of stay. The model was weighed accordingly and covariates (e.g., age) were considered in the model. Heart disease was found to be the most common pre-existing condition of COVID-19 hospitalized patients in this study. Azithromycin, an antibacterial in the Watch category list, was used extensively (33-65 DDD per 100 bed-days). Oseltamivir, an antiviral approved by the FDA for influenza was the most prescribed antiviral. In addition, favipiravir was found to be a significant factor in improving patients' COVID-19 outcomes and decreasing their length of stay. This study strongly suggests that COVID-19 patients' received polypharmacy for their treatment. However, most of the drugs used did not reach statistical significance in improving the patients' condition or decreasing the length of stay. Further studies to support drug use are needed.

Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method

During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Antibiotic Prescribing in Children Hospitalized With COVID-19 and Multisystem Inflammatory Syndrome in Spain: Prevalence, Trends, and Associated Factors

The SARS-CoV-2 pandemic has caused an increase in antibiotic use in different settings. We describe the antibiotic prescribing prevalence, associated factors and trends, as well as concomitant bacterial infections in children hospitalized with COVID-19 or multisystemic inflammatory syndrome related to SARS-CoV-2 in Spain.

Inappropriate Antibiotic Use in Zimbabwe in the COVID-19 Era: A Perfect Recipe for Antimicrobial Resistance

The global COVID-19 pandemic has resulted in an upsurge in antimicrobial use. The increase in use is multifactorial, and is particularly related to the empirical treatment of SARS-CoV-2 and suspected coinfections with antimicrobials and the limited quality of diagnostics to differentiate viral and bacterial pneumonia. The lack of clear clinical guidelines across a wide range of settings, and the inadequacy of public health sectors in many countries, have contributed to this pattern. The increased use of antimicrobials has the potential to increase incidences of antimicrobial resistance, especially in low-resource countries such as Zimbabwe already grappling with multidrug-resistant micro-organism strains. By adopting the antimicrobial stewardship principles of the correct prescription and optimised use of antimicrobials, as well as diagnostic stewardship, revamping regulatory oversight of antimicrobial surveillance may help limit the occurrence of antimicrobial resistance during this pandemic.

Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature

BACKGROUND

Despite the adoption of strict infection prevention and control measures, many hospitals have reported outbreaks of multidrug-resistant organisms (MDRO) during the Coronavirus 2019 (COVID-19) pandemic. Following an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in our institution, we sought to systematically analyse characteristics of MDRO outbreaks in times of COVID-19, focussing on contributing factors and specific challenges in controlling these outbreaks.

METHODS

We describe results of our own CRAB outbreak investigation and performed a systematic literature review for MDRO (including Candida auris) outbreaks which occurred during the COVID-19 pandemic (between December 2019 and March 2021). Search terms were related to pathogens/resistance mechanisms AND COVID-19. We summarized outbreak characteristics in a narrative synthesis and contrasted contributing factors with implemented control measures.

RESULTS

The CRAB outbreak occurred in our intensive care units between September and December 2020 and comprised 10 patients (thereof seven with COVID-19) within two distinct genetic clusters (both ST2 carrying OXA-23). Both clusters presumably originated from COVID-19 patients transferred from the Balkans. Including our outbreak, we identified 17 reports, mostly caused by Candida auris (n = 6) or CRAB (n = 5), with an overall patient mortality of 35% (68/193). All outbreaks involved intensive care settings. Non-adherence to personal protective equipment (PPE) or hand hygiene (n = 11), PPE shortage (n = 8) and high antibiotic use (n = 8) were most commonly reported as contributing factors, followed by environmental contamination (n = 7), prolonged critical illness (n = 7) and lack of trained HCW (n = 7). Implemented measures mainly focussed on PPE/hand hygiene audits (n = 9), environmental cleaning/disinfection (n = 9) and enhanced patient screening (n = 8). Comparing potentially modifiable risk factors and control measures, we found the largest discrepancies in the areas of PPE shortage (risk factor in 8 studies, addressed in 2 studies) and patient overcrowding (risk factor in 5 studies, addressed in 0 studies).

CONCLUSIONS

Reported MDRO outbreaks during the COVID-19 pandemic were most often caused by CRAB (including our outbreak) and C. auris. Inadequate PPE/hand hygiene adherence, PPE shortage, and high antibiotic use were the most commonly reported potentially modifiable factors contributing to the outbreaks. These findings should be considered for the prevention of MDRO outbreaks during future COVID-19 waves.

Some issues of safety of antimicrobial therapy in COVID-19 patients

Currently, there is a lack of evidence for empiric use of antimicrobial agents in most patients with COVID-19 in outpatient and hospital settings as the overall proportion of secondary bacterial infections in COVID-19 is quite low. This literature review summarizes data on changes in antimicrobial resistance over the course of COVID-19 pandemic, especially in nosocomial ESKAPE pathogens. The other significant consequences of excessive and unnecessary administration of antibiotics to COVID-19 patients including risk of Clostridioides difficile infection and adverse effects of antimicrobial agents are also discussed.

COVID-19: a boon or a bane for the microbiologists

BACKGROUND

In the situation where COVID-19 pandemic has placed unprecedented demands and pressure on the health care system, we wanted to analyze how the medical microbiologists of our country were affected. Was it actually an opportunity to showcase the specialty or was it a doom? A debate was organized as a key session in the national e-conference of the Indian Association of Medical Microbiologists, held on 10 December 2020.

OBJECTIVES

The objective of the debate was to examine and analyze the various positive as well as negative impacts of COVID-19 on the discipline of the medical microbiology of our country.

CONTENT

Before the debate a voting session was conducted to assess the opinion of the audience followed by a very interesting debate where both the speakers presented their view points. The points in favor of the discipline were, mainly up-gradation of the specialty of microbiology in terms of learning, skill development, infrastructure, networking & research opportunities related to COVID-19. While the main points against were, nerve wracking work load without much acknowledgement, performance pressure from hospital administration to maintain rapid turnaround time, and a forceful neglect of all other infectious diseases like tuberculosis and antimicrobial resistance which were the key battle fields of the medical microbiologists. Postgraduate & even undergraduate training programs got completely derailed to their disadvantage. By the end of the debate, it was concluded that COVID-19 was neither a boon nor a bane to the microbiologists. A balanced approach to the problem in hand is required without ignoring the pre-existing infectious diseases in our country. The post debate voting swayed the audience considerably for it to be a bane & the faculty debating for boon had a huge margin to begin with but finally won with a whisker indicating the intensity of the debate.

Increased Use of Antibiotics in the Intensive Care Unit During Coronavirus Disease (COVID-19) Pandemic in a Brazilian Hospital

Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic. Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment. Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat. Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial's use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Global health emergencies during the pandemic and their solutions

In this review, we evaluated health care problems, which were not common before pandemic outbreak but have been common issues after its appereance and approaches to control pandemic considering its influences on people. We revised current health care developing approaches under the light of experience obtained throughout the pandemic so far. The aim is to be prepared in advance for possible upcoming pandemics. As in Covid 19 pandemics, such long lasting and widely affecting situations, durability is also very important together with flexibility and quickness. To provide durability, we need global policies taking the health to its center as well as health system policies.

Impact of the COVID-19 Pandemic on Community Antibiotic Prescribing and Stewardship: A Qualitative Interview Study with General Practitioners in England

The COVID-19 pandemic has had a profound impact on the delivery of primary care services. We aimed to identify general practitioners’ (GPs’) perceptions and experiences of how the COVID-19 pandemic influenced antibiotic prescribing and antimicrobial stewardship (AMS) in general practice in England. Twenty-four semi-structured interviews were conducted with 18 GPs at two time-points: autumn 2020 (14 interviews) and spring 2021 (10 interviews). Interviews were audio-recorded, transcribed and analysed thematically, taking a longitudinal approach. Participants reported a lower threshold for antibiotic prescribing (and fewer consultations) for respiratory infections and COVID-19 symptoms early in the pandemic, then returning to more usual (pre-pandemic) prescribing. They perceived the pandemic as having had less impact on antibiotic prescribing for urinary and skin infections. Participants perceived the changing ways of working and consulting (e.g., proportions of remote and in-person consultations) in addition to changing patient presentations and GP workloads as influencing the fluctuations in antibiotic prescribing. This was compounded by decreased engagement with, and priority of, AMS due to COVID-19-related urgent priorities. Re-engagement with AMS is needed, e.g., through reviving antibiotic prescribing feedback and targets/incentives. The pandemic disrupted, and required adaptations in, the usual ways of working and AMS. It is now important to identify opportunities, e.g., for re-organising ways of managing infections and AMS in the future.

Genetic support of carbapenemases: a One Health systematic review and meta-analysis of current trends in Africa

Antimicrobial resistance (AMR) is a public health threat globally. Carbapenems are β-lactam antibiotics used as last-resort agents for treating antibiotic-resistant infections. Mobile genetic elements (MGEs) play an important role in the dissemination and expression of antimicrobial resistance genes (ARGs), including the mobilization of ARGs within and between species. The presence of MGEs around carbapenem-hydrolyzing enzymes, called carbapenemases, in bacterial isolates in Africa is concerning. The association between MGEs and carbapenemases is described herein. Specific plasmid replicons, integrons, transposons, and insertion sequences were found flanking specific and different carbapenemases across the same and different clones and species isolated from humans, animals, and the environment. Notably, similar genetic contexts have been reported in non-African countries, supporting the importance of MGEs in driving the intra- and interclonal and species transmission of carbapenemases in Africa and globally. Technical and budgetary limitations remain challenges for epidemiological analysis of carbapenemases in Africa, as studies undertaken with whole-genome sequencing remained relatively few. Characterization of MGEs in antibiotic-resistant infections can deepen our understanding of carbapenemase epidemiology and facilitate the control of AMR in Africa. Investment in genomic epidemiology will facilitate faster clinical interventions and containment of outbreaks.

COVID-19: Impact on prescribing and antimicrobial resistance

The onset of the COVID-19 pandemic challenged health-care systems focusing their activity on patients infected with SARS-CoV-2. Previous experience with co-infections and superinfections in patients infected with other coronaviruses (SARS-CoV and MERS), the influenza patients admitted to hospitals and prevention of the unknown led to the increased empirical use of broad-spectrum antibiotics in hospitals. The breakdown of antimicrobial stewardship and infection control programs determine an increase in infections due to multi-drug-resistant bacteria, particularly in intensive care units. Most of these infections are related to high-risk carbapenemase-producing clones and occasionally with resistance to new β-lactamβ-lactamase inhibitor combinations. On the contrary, in the primary care, there has been a decrease in the use of antimicrobials during the first wave, although it would not have had a significant impact on pathogens associated with community-acquired infections. The accumulated experience reaffirms the need to maintain antimicrobial stewardship and infection control programs in future health crises.