The impact of the COVID-19 pandemic on antibiotic consumption and prevalence of pathogens in primary and secondary healthcare settings in Northern Ireland

Antimicrobial Prescribing Patterns in GP Practices in Northern Ireland

Introduction: Antimicrobial resistance (AMR) is a global health threat requiring immediate attention as it is set to cause ten million deaths worldwide by 2050, overtaking that of cancer. Continuation of overuse and/or misuse of these crucial medicines will prevent future generations from reaping the benefits, as the pandemic of AMR spirals out of control. Aims: The primary aim of this study was to investigate antimicrobial prescribing patterns in General Practices throughout Northern Ireland. A secondary aim was to analyse the impact of the COVID-19 pandemic on antimicrobial prescribing and consumption patterns in GP practices in Northern Ireland. Methods: A retrospective, cross-sectional quantitative study was designed to measure, analyse, and evaluate the antimicrobial prescribing patterns within GP practices in Northern Ireland, using open access Business Services Organisation (BSO) data. Results: A total of 3,168.78 kg of antibacterial drugs were prescribed in primary care throughout the duration of the study. Penicillins were the most prescribed class (59.79%), followed by tetracyclines (10.68%) and macrolides (9.53%). Access group antibiotics were the most frequently prescribed (79.35%), followed by Watch group antibiotics (20.64%), with Reserve group antibiotics equating to nearly 0% despite being prescribed. The Derry GP Federation prescribed and dispensed the greatest amount of antibiotics overall in Northern Ireland (10.90%). Despite there being no significant difference in antibiotic prescribing amongst GP federations prior to and during the COVID-19 pandemic (unpaired t-test, p > 0.05), there were differences in prescribing of individual drug classes throughout this period. Conclusions: Despite meeting World Health Organisation (WHO) targets, GP practices within Northern Ireland must achieve more to further reduce antimicrobial consumption. Although antibiotic prescribing rates here are on the decline, there was no significant difference in prescribing amongst GP federations pre- and midst-COVID-19 pandemic, thus sufficient strategies such as increased communication between colleagues and supportive measures must be implemented within GP practices to enhance antimicrobial stewardship (AMS) across Northern Ireland.

Impact of the COVID-19 Pandemic on Inpatient Antibiotic and Antifungal Drug Prescribing Volumes in Germany

BACKGROUND

Previous studies found that the coronavirus disease 2019 (COVID-19) pandemic had a variable impact on the consumption of antimicrobial drugs in human medicine, with trends in several European countries differing between community and inpatient prescribing.

AIM

This study analysed changes in the volumes and use density of antibacterial and antifungal drugs dispensed in acute care hospitals in Germany between 2019 and 2022.

METHODS

Surveillance data for the four years available from 279 hospitals were expressed as the total volumes of daily doses or as use density (daily doses per 100 patient/occupied bed days) per year and analysed descriptively, using recommended hospital-adapted daily dose definitions (RDDs) and (as sensitivity analysis) WHO/ATC-defined daily dose definitions (DDD). Hospitals were stratified according to size (number of beds), university affiliation, and location (East, West, South).

RESULTS

There were significant decreases in both the total number of patient days and antibacterial drug volumes in 2020 through 2022 compared with 2019. The relative changes between 2019 and 2020, 2021, and 2022 were -12.8%, -13.5%, and -13.3% for patient days, and -9.7%, -11.0%, and -10.1% for antibacterial RDDs, respectively. Broad-spectrum betalactams, notably piperacillin-tazobactam and carbapenems, increased in volume, unlike most other drug classes. The resulting antibacterial drug use density was slightly but significantly increased, with pooled means (and medians) of 43.3 (40.0) RDD/100 in 2019 compared to 44.8 (41.7), 44.5 (40.80), and 44.9 (41.7) RDD/100 in the years 2020 through 2022, respectively. Antifungal drug volumes and use density increased after 2019 and peaked in 2021 (the difference between 2019 and 2021 for total volumes was +6.4%, and that for pooled mean use density values was +22.9%, respectively). These trends were similar in the different hospital strata and comparable when DDDs instead of RDDs were used.

CONCLUSIONS

Similar to what has been observed in a majority of European countries, the total volume of antibacterial drug use in German acute care hospitals decreased with the pandemic, without a rebound phenomenon in 2022. In association with restricted hospital capacities and presumably more immunocompromised general medicine patients, however, inpatient prescribing of (primarily broad-spectrum) antibacterials and of antifungal drugs increased.

A scoping review of bacterial resistance among inpatients amidst the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic.

METHODS

We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies.

RESULTS

In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results.

CONCLUSIONS

The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19.

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.

Antibiotic Consumption 2017-2022 in 30 Private Hospitals in France: Impact of Antimicrobial Stewardship Tools and COVID-19 Pandemic

Our aim was to determine the impact of antimicrobial stewardship tools (ASTs) and the COVID-19 pandemic on antibiotic consumption (AC). We used the national software Consores® to determine AC in DDD/1000 days of hospitalization from 2017 to 2022 in voluntary private hospitals in France. The ASTs considered were: 1. internal guidelines; 2. the list of antibiotics with restricted access; 3. the presence of an antibiotic referent or 4. an ID specialist; and 5. proof of an annual meeting on antimicrobial resistance. Institutions with dedicated units for COVID-19 patients were specified. In 30 institutions, the total AC varied from (means) 390 to 405 DDD/1000 DH from 2017 to 2022. Fluoroquinolones and amoxicillin/clavulanate consumption decreased from 50 to 36 (p = 0.003) and from 112 to 77 (p = 0.025), respectively, but consumption of piperacillin/tazobactam increased from 9 to 21 (p < 0.001). Over the study period, 10 institutions with ≤2 AST had lower AC compared to 20 institutions with ≥3 AST (p < 0.01). COVID-19 units opened in 10 institutions were associated with a trend toward higher macrolide consumption from 15 to 25 from 2017 to 2020 (p = 0.065) and with an acceleration of piperacillin/tazobactam consumption from 2020 to 2022 (p ≤ 0.003). Antibiotic consumption in 30 private hospitals in France was inversely related to the number of AST. The COVID-19 pandemic was associated with limited impact on AC, but special attention should be paid to piperacillin/tazobactam consumption.

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.