How did the COVID-19 pandemic impact antibiotic prescribing and antimicrobial stewardship in acute care settings?

This Problem is based on work published in http://doi: 10.1186/s12889-023-15072-5 [1]

 Introduction:

Sir Alexander Fleming mentioned the concept of AMR during his Nobel Prize lecture (Chung et al., 2013). The rise in multi-drug-resistant infections threatens global health through significant morbidity, mortality, and economic loss. Following the O’Neill review and findings in 2016, the number of deaths from AMR infections was estimated to reach 10 million annually due to the AMR crisis (O’Neill, 2014). AMR is a silent pandemic and one of the biggest threats to global health (WHO, 2019). In 2019, it was estimated that more than 1.2 million people died worldwide from AMR (Murray, 2022). Public Health England has also emphasised the need for AMS implementation to maintain the appropriate use of antibiotics (PHE, 2015).

Antimicrobial Stewardship is a coherent set of actions that promotes the effective use of antibiotics. It aims to maintain the optimal selection, dosage, route, and duration of antibiotic treatment (NICE, 2015). AMS Strategies aimed at improving the appropriate prescription of antibiotics in humans across all healthcare settings may be considered a part of 'antimicrobial stewardship.' The literature suggests a multitude of antimicrobial stewardship tools, interventions, and activities (collectively referred to as 'strategies') that can streamline and enhance antimicrobial use and educate prescribers (ESPAUR, 2021). 

Epidemiological studies have clearly demonstrated a direct relationship between antimicrobial use and the emergence of resistant strains, advocating a multi-step approach to enhance AMS strategies (Barlam et al., 2016). The process of prescribing antibiotics involves a series of steps: initially diagnosing an infection, starting treatment in line with local guidelines, and then continually adjusting the antibiotic therapy based on new clinical data that emerges (BSAC, 2015). Various healthcare professionals, such as doctors, nurses, microbiologists, and pharmacists, perform critical roles at different stages of the antibiotic prescribing pathway. Interventions and strategies aiming to improve antibiotic prescribing and promote AMS have been extensively researched. Such interventions, targeting different points of the antibiotic prescribing pathway, have proven to be clinically effective for hospital inpatients (Barlam et al., 2016). They have resulted in increased appropriateness of antibiotic therapy, reduced antibiotic consumption and therapy duration, and shorter hospital stays (Montrucchio et al., 2019). 

The outbreak of infection caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2; COVID-19) from Wuhan, China, in December 2019 escalated rapidly to become a global pandemic (Phelan, Katz and Gostin, 2020). In October 2023, the estimated number of total deaths was 6 million, 10% of the worldwide deaths of 60 million (WHO, 2023). Recent evidence suggests that, as a consequence of the COVID-19 pandemic, increasing numbers of patients admitted to hospitals have been prescribed empirical antimicrobial therapy, which may not always be appropriate, potentially increasing the number of resistant infections globally (Murgadella-Sancho et al., 2021; Zhou et al., 2020). Consideration for AMR and AMS focused on supporting the selection of optimal empirical therapies and appropriate de-escalation or discontinuation of antimicrobials when bacterial co-infection is present or absent is essential (Hamidi et al., 2021).

Figure 2. COVID-19 pandemic and antimicrobial resistance (AMR) silent pandemic. Photo credit Rasha Abdelsalam Elshenawy

Research aims and objectives.

Aims: To investigate the implementation of AMS and antibiotic prescribing practices Prior-to-Pandemic (PP) and During-the-Pandemic (DP), as well as to explore the knowledge, attitudes, and perceptions of health professionals towards antibiotic prescribing and AMS implementation during the COVID-19 pandemic in a secondary care setting in the UK.

Objectives:

1. To assess the implementation of AMS in acute care settings among adult patients through a systematic review of existing literature from 2000 to 2020?

2. To determine the prevalence of inappropriate antibiotic prescribing in adult patients at the NHS Foundation Trust, both PP and DP in 2019 and 2020, by conducting a retrospective cross-sectional review of patient records.

3. To evaluate the implementation of AMS among adult patients admitted to the NHS Foundation Trust both PP and DP in 2019 and 2020, utilising a retrospective cross-sectional review of patient records.

4. To investigate healthcare professionals' knowledge, attitudes, and perceptions regarding antibiotic prescribing, AMR, and AMS practices through a cross-sectional prospective survey questionnaire.

Research Questions: The following research questions have been formulated for each study:

Study One: Systematic Literature Review:

1. How has AMS been implemented in acute care settings as reflected in the literature from 2000 to 2020?

Study Two: Retrospective Patient Records Review Study:

1. What is the prevalence of inappropriate antibiotic prescribing among adult patients at the NHS Foundation Trust both PP and DP in an acute care setting?

2. How effectively has AMS been implemented among adult patients admitted to the NHS Foundation Trust both PP and DP in 2019 and 2020 in an acute care setting?

3. Which factors influenced antibiotic prescribing and AMS implementation among adult patients admitted to the NHS Foundation Trust both PP and DP in 2019 and 2020 in an acute care setting?

Study Three: Prospective Survey Questionnaire Study:

1. What is the level of healthcare professionals' knowledge about antibiotic prescribing, AMR, and AMS practices during the pandemic in an acute care setting?

2. What are the attitudes and perceptions of healthcare professionals towards antibiotic prescribing, AMR, and AMS practices during the pandemic in an acute care setting?

3. Which factors influence healthcare professionals' attitudes toward AMS practices during the pandemic in an acute care setting?

Methods overview:

This research project required a combination of retrospective and prospective research methods to achieve its aim and objectives.

The Video of this research project: https://youtu.be/fx6SWsluB8o?si=mpwR1is5efthdB4K

A comprehensive systematic literature review, designated as Study 1, was conducted to explore the implementation of antimicrobial stewardship in hospitalised adult patients in acute care settings both prior to and during the COVID-19 pandemic. This review explored the strategies, measures, and tools used for AMS implementation in acute care settings. It also identified healthcare professionals, including doctors, pharmacists, and nurses. These insights were subsequently applied in Study 2 to evaluate antibiotic prescribing practices and assess the prevalence of inappropriate antibiotic prescribing in an acute care setting in England.

The systematic literature review led to the retrospective study in this research project, Study 2, which investigated AMS implementation in acute care settings prior to and during the pandemic. In this retrospective study, primary data were extracted from 640 electronic patient records and analysed using descriptive and regression analyses with the Statistical Package for the Social Sciences (SPSS) software. This study evaluated AMS implementation and the prevalence of inappropriate antibiotic prescribing both prior to and during the pandemic and identified factors influencing inappropriate antibiotic prescribing in an acute care setting during these periods. As revealed in Study 2, AMS requires a collaborative effort among healthcare professionals to ensure the judicious use of antibiotics. Additionally, it was found that antibiotic prescribing behaviour was affected during the COVID-19 pandemic.

The prospective survey questionnaire study, referred to as Study 3, involved 240 healthcare professionals, including doctors, pharmacists, and nurses. Its design was aligned with the research objectives, drawing on insights from the preceding literature review and PHE analysis of behavioural changes in antibiotic prescribing within acute care settings. It also incorporated insights from the framework on enhancing the science of deprescribing (Linsky et al., 2019). Study 3 further investigated the issues of inappropriate antibiotic prescribing and AMS implementation strategies identified in Study 2. Additionally, it probed into healthcare professionals' understanding, attitudes, and perceptions regarding antibiotic prescribing and AMS practices, especially during the COVID-19 pandemic, in an acute care setting. The collected anonymous questionnaire responses were analysed through descriptive and regression analyses using the SPSS software. The outcomes of Study 3 also examined the impact of the COVID-19 pandemic on AMS practices.

In terms of project design, this research encompasses three sequential studies designed to comprehensively address all the planned objectives, as illustrated in the flowchart (Figure 1).

Figure 3. Description of the research project three sequential studies
Research problem: How did the COVID-19 pandemic impact antibiotic prescribing and antimicrobial stewardship in acute care settings?

Registration: The protocol of this study was published in the ISRCTN related to the WHO Criteria.