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

A systematic review of national interventions and policies to optimize antibiotic use in healthcare settings in England

OBJECTIVES

To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013-2022).

METHODS

A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013-2018), National Action Plan (2019-2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014-2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted.

FINDINGS

Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n = 9); classifications (n = 1); guidance and toolkits (n = 22); monitoring and feedback (n = 17); professional engagement and training (n = 19); prescriber tools (n = 12); public awareness (n = 17); workforce and governance (n = 12).Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals.

CONCLUSIONS

Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable.

Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment

BACKGROUND

In the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities.

METHODS

A retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017-2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time.

RESULTS

All public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups.

CONCLUSIONS

Results of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

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.

Healthcare commissioners' experience with antibiotic resistance during the COVID-19 pandemic in Saudi Arabia: a qualitative study

Introduction

The occurrence of antibiotic resistance (AR) has become a critical issue during the Novel coronavirus disease 2019 (COVID-19) pandemic. This study explores the experiences of healthcare commissioners with AR during the COVID-19 pandemic, identifies challenges, and provides recommendations for combating AR during pandemics.

Methods

This qualitative study was multi-centered and used a phenomenological approach. Semi-structured interviews were conducted between December 2022 and January 2023 among 11 health commissioners using video calls.

Results

Seven themes emerged from the data, including knowledge of AR and its consequences, the antibiotic prescription system, the future of AR and potential contributory factors, the impact of COVID-19 on AR and their relationship, the experience of AR during the COVID-19 pandemic in healthcare facilities, barriers that prevent the misuse of antibiotics during pandemics, and recommendations regarding antibiotic resistance during pandemics.

Conclusion

The findings of this study could be used to inform policy and practice for government healthcare workers (HCWs) and the public. Furthermore, this study identified the main challenges of AR during the pandemic, and the recommendations of health commissioners were provided accordingly. Such recommendations could be beneficial on a national and international scale to reduce the impact of future pandemics on AR.

Abbreviations

COVID-19: Novel coronavirus disease 2019; AR: Antibiotic Resistance; IPC: Infection prevention and control; MDRO: multi-drug resistant organism; ASP: Antimicrobial Stewardship Program; HCW: Healthcare worker; KSA: Kingdom of Saudi Arabia; WHO: World Health Organization; MOH: Ministry of Health; MOEWA: Ministry of Environment, Water, and Agriculture; AMR: Antimicrobial Resistance; PHCC: Primary Healthcare Center.

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

AIM

To evaluate the impact of the COVID-19 pandemic on the patterns of antimicrobial use and the incidence of pathogens in primary and secondary healthcare settings in Northern Ireland.

METHODS

Data were collected on antibiotic use and Gram-positive and Gram-negative pathogens from primary and secondary healthcare settings in Northern Ireland for the period before (January 2015-March 2020) and during (April 2020-December 2021) the pandemic. Time series intervention analysis methods were utilized.

RESULTS

In the hospital setting, the mean total hospital antibiotic consumption during the pandemic was 1864.5 defined daily doses (DDDs) per 1000 occupied-bed days (OBD), showing no significant change from pre-pandemic (P = .7365). During the pandemic, the use of second-generation cephalosporins, third-generation cephalosporins, co-amoxiclav and levofloxacin increased, there was a decrease in the percentage use of the hospital Access group (P = .0083) and an increase in the percentage use of Watch group (P = .0040), and the number of hospital Klebsiella oxytoca and methicillin-susceptible Staphylococcus aureus cases increased. In primary care, the mean total antibiotic consumption during the COVID-19 pandemic was 20.53 DDDs per 1000 inhabitants per day (DID), compared to 25.56 DID before the COVID-19 pandemic (P = .0071). During the pandemic, there was a decrease in the use of several antibiotic classes, an increase in the percentage use of the Reserve group (P = .0032) and an increase in the number of community-onset Pseudomonas aeruginosa cases.

CONCLUSION

This study provides details of both changes in antibiotic consumption and the prevalence of infections in hospitals and primary care before and during the COVID-19 pandemic that emphasize the importance of antimicrobial stewardship in pandemic situations.

Antimicrobial Stewardship in COVID-19 Patients: Those Who Sow Will Reap Even through Hard Times

BACKGROUND

Since the SARS-CoV-2 pandemic emerged, antimicrobial stewardship (AS) activities need to be diverted into COVID-19 management.

METHODS

In order to assess the impact of COVID-19 on AS activities, we analyzed changes in antibiotic consumption in moderate-to-severe COVID-19 patients admitted to four units in a tertiary-care hospital across three COVID-19 waves. The AS program was introduced at the hospital in 2018. During the first wave, COVID-19 forced the complete withdrawal of hospital AS activities. In the second wave, antibiotic guidance calibration for COVID-19 patients was implemented in all units, with enhanced stewardship activities in Units 1, 2, and 3 (intervention units). In a controlled before and after study, antimicrobial usage during the three waves of the COVID-19 pandemic was compared to the 12-month prepandemic unit (Unit 4 acted as the control). Antibiotic consumption data were analyzed as the overall consumption, stratified by the World Health Organization AWaRe classification, and expressed as defined-daily-dose (DDD) and days-of-therapy (DOT) per 1000 patient-day (PD).

RESULTS

In the first wave, the overall normalized DOT in units 2-4 significantly exceeded the 2019 level (2019: 587 DOT/1000 PD ± 42.6; Unit 2: 836 ± 77.1; Unit 3: 684 ± 122.3; Unit 4: 872, ± 162.6; p < 0.05). After the introduction of AS activities, consumption decreased in the intervention units to a significantly lower level when compared to 2019 (Unit 1: 498 DOT/1000 PD ± 49; Unit 2: 232 ± 95.7; Unit 3: 382 ± 96.9; p < 0.05). Antimicrobial stewardship activities resulted in a decreased amount of total antibiotic consumption over time and positively affected the watch class and piperacillin-tazobactam use in the involved units.

CONCLUSIONS

During a pandemic, the implementation of calibrated AS activities represents a sound investment in avoiding inappropriate antibiotic therapy.

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.