The Impact of the COVID-19 Pandemic on Antimicrobial Stewardship in Acute-Care Settings and the Pharmacist Role

Introduction: Antimicrobial resistance (AMR) is a major global health issue, causing 1.2 million deaths yearly and increasing by 15% during the COVID-19 pandemic. In the UK, bloodstream infection (BSIs) cases rose by 11.7% from 2018 to 2022. The overall AMR infections and priority pathogen AMR BSIs decreased by 1.6% and 4.6%, respectively. Antimicrobial stewardship (AMS) promotes judicious antibiotic use, but the COVID-19 pandemic increased AMR by 15%. Although there are paramount data on the impact of COVID-19 on AMS, empirical data on AMS implementation during the pandemic are lacking. The UK aims to reduce antimicrobial-resistant infections by 10% by 2025. As of 2021, efforts to monitor and regulate antibiotic use in secondary care settings are ongoing. Despite extensive data on COVID-19's impact on AMS, detailed information on AMS practices during the pandemic is scarce. Aim: To investigate antibiotic prescribing and AMS implementation in 2019, prior to the pandemic, and in 2020, during the pandemic, at an NHS Foundation Trust in England. Additionally, the study aimed to explore healthcare professionals' perspectives on antibiotic prescribing and AMS practices during the COVID-19 pandemic. Methods and data analysis: This study employed both retrospective and prospective postpositivist research methods. Study 1 involved conducting a systematic literature review to investigate the implementation of AMS in acute care settings, both Prior-to-pandemic (PP) and During-the-pandemic (DP). Study 2, a retrospective cross-sectional study, focused on assessing the prevalence of inappropriate antibiotic prescribing among hospitalised adults during the PP and DP periods. Data from this study were analysed using descriptive statistics and regression analysis in SPSS. Study 3 was a cross-sectional, prospective survey involving healthcare professionals. It aimed to understand their knowledge, attitudes, and perceptions towards antibiotic prescribing and AMS practices during the pandemic, with the findings similarly analysed using descriptive statistics and regression analysis. Results: Study 1 identified AMS implementation strategies and quality improvement projects used in acute care settings before and during the COVID-19 pandemic. Study 2, conducted at Bedfordshire Hospitals NHS Foundation Trust, revealed that the prevalence of inappropriate empirical antibiotic prescribing was 50% PP and 49% DP among hospitalised adults. Significant differences were observed in the AMS interventions 'Continue Antibiotics' and 'De-escalation' during the pandemic, with odds ratios of 3.36 and 2.77, respectively, indicating notable changes in prescribing practices. Study 3 showed that healthcare professionals had good knowledge in only two areas related to AMR, recognising its impact on public health. Over 80% reported negative effects of the pandemic on AMS activities, especially in antibiotic review and education. Furthermore, (42% n=240) strongly agreed that antimicrobial misuse during COVID-19 could worsen resistance. The study also highlighted the importance of age, gender, professional background, and experience in influencing AMS-related knowledge, attitudes, and practices. These findings underline the pandemic's profound impact on AMS and the necessity for evolved strategies in future health crises. Conclusion: The COVID-19 pandemic has had a detrimental impact on AMS activities, highlighting the urgent need to enhance antibiotic prescribing practices and ensure the sustainability of AMS implementation in the UK. Continuously developing the skills of healthcare professionals through education and innovative tools, such as an AMS dynamic dashboard and an AMS card, is vital for improving patient care and combating AMR effectively. These tools will help adapt to changing antibiotic resistance patterns and enhance broad-spectrum antibiotic use. Data sharing on AMS practices and multidisciplinary communication is essential for effective AMS. Further research is necessary, as this study, confined to a secondary care setting, focused only on respiratory tract infections and did not include children.