COVID-19 Impact on Antimicrobial Stewardship: Consequences and Silver Linings

The COVID-19 pandemic has resulted in almost 470 million confirmed cases and over 6 million deaths worldwide.¹ Consequently, health care providers (HCPs) in both outpatient and inpatient settings have had to adjust their workflow and keep up-to-date with COVID-19 literature, emergency-use authorizations, and treatment recommendations. Amid the uncertainty, infectious diseases (ID) clinicians, especially those leading antimicrobial stewardship programs (ASPs), have taken on additional leadership roles to organize and maintain their institutions' COVID-19 treatment guidelines.

The negative impacts of COVID-19 cannot be understated, such as the tremendous toll on the health care community and the potential impact of exacerbating resistance due to overuse of empiric antimicrobials; however, silver linings deserve to be highlighted. These include renewed recognition of the versatile skill set of ID specialists, as well as the opportunity to strengthen multidisciplinary working relationships.

In this article, we will review both the negative and positive effects of COVID-19 and its impact on ASP workload.

INCREASED BURNOUT

Burnout among HCPs was a topic of concern prior to the COVID-19 pandemic and was associated with reductions in patient satisfaction, waning provider empathy, and increased medical errors.² Since December 2019, there has been a heightened awareness of how the pandemic has contributed to HCP burnout; however, the true prevalence of burnout among HCPs is unknown.

A study conducted in the United Kingdom attempted to estimate burnout rates through a questionnaire, which included variables validated by established measures such as the Copenhagen Burnout Inventory.³ Almost 80% of the UK participants (424/539) reported moderate to severe burnout. Conversely, in a Japanese study led by Matsuo et al, 31% (98/312) of HCPs reported burnout.⁴

Additionally, when compared with physicians, burnout prevalence was almost 5 times higher for nurses (odds ratio [OR], 4.9; 95% CI, 2.2-11.2) and pharmacists (OR, 4.9; 95% CI, 1.3-19.2), 6 times higher for laboratory medical technicians (OR, 6.1; 95% CI, 2.0-18.5), and 16 times higher for radiological technicians (OR, 16.4; 95% CI, 4.3-61.6).⁴

Patient demographics, including younger age, female sex, and presence of comorbid conditions including preexisting depression, may also increase the risk for burnout.^3,5,6 Recognizing burnout among our HCPs is the first step in providing interventions to reduce burnout, such as maintaining open communication with coworkers and supervisors about job stress, increasing sense of self-control by keeping a consistent daily routine, and engaging in mindfulness techniques.⁷ Resources to support HCPs should be offered to prevent burnout, such as the tools provided on the CDC’s Support for Public Health Workers and Health Professionals website.⁷

ANTIMICROBIAL OVERUTILIZATION

Another repercussion of COVID-19 is the potential exacerbation of antimicrobial resistance due to antimicrobial overuse. Unnecessary empiric antibiotic use was commonly reported early in the COVID-19 pandemic, despite low reported rates of bacterial coinfection—approximately 8% to 19% of adult patients hospitalized for COVID-19.^8-10

A review of early COVID-19 prescribing trends found that 25% to 70% of patients who were severely ill with COVID-19 were empirically started on antibiotics to cover for possible community-acquired bacterial pneumonia (CABP).¹¹ Continuation of unnecessary antibiotic therapy during hospitalization is also an issue because approximately 15% to 24% of patients hospitalized with COVID-19 will acquire a secondary bacterial infection.^9-10

Therefore, ASP efforts to monitor antimicrobial overuse increased because patients required case-by-case evaluation to assess the need for initiating and continuing antimicrobial therapy.

RECOGNIZING THE VALUE OF ANTIMICROBIAL STEWARDSHIP EXPERTISE

Due to the worldwide and profound impact of COVID-19, both the public and the health care sector looked toward the expertise of ID clinicians to lead them through the pandemic. On a national level, the Society of Infectious Diseases Pharmacists (SIDP) provided clinicians and patients with valuable, real-time information and useful tools about therapeutics, vaccines, and more.¹²

SIDP’s YouTube channel, which houses over 30 COVID-19 videos with more than 160,000 views (as of April 2022), showcased evidence-based reviews of COVID-19 therapeutics provided by ID pharmacy experts. SIDP’s Breakpoints podcast also shared stories from those on the front lines and their approach to addressing relevant issues. COVID-19 gave ID pharmacists, who were already equipped to handle the ever-changing demands of the health care system, an opportunity to further demonstrate their value.

ASPs were also paramount in the fight against the pandemic. Throughout the country, they led the efforts within their own institutions to discuss rapidly changing information, create COVID-19 treatment guidelines, and provide education. Additionally, ASPs were presented with a unique opportunity to utilize existing knowledge and skill sets to optimize and intervene on inappropriate antimicrobial usage. Various stewardship groups have shared their approach to integrating COVID-19 into their daily clinical practice, some of which include maintaining the COVID-19 treatment guidelines and utilizing molecular diagnostic tools to help differentiate viral and bacterial pneumonia.

Creation of institution-specific COVID-19 treatment guidelines provide frontline providers with the most up-to-date recommendations. When coupled with education, the employment of institution-specific guidelines has been shown to reduce unnecessary use of empiric antibiotics. In a single-center, quasi-experimental study, education and recommendations were provided to COVID-19 providers. Implementation of a COVID-19 treatment guideline with provider education resulted in a significant reduction in empiric CABP antibiotics for patients with COVID-19 (74.5% preintervention vs 42% postintervention; P <.001).¹³

Molecular respiratory tests may also be used as a stewardship tool for COVID-19 patients when a bacterial coinfection or secondary infection is suspected. Three studies evaluated the microbiological performance of BioFire FilmArray pneumonia panels, including the pneumonia panel and pneumonia-plus panel, in critically ill patients with COVID-19.^14-16 High rates of test sensitivity (89.3%-100%) were reported across all studies, supporting the use of this rapid diagnostic test for ruling out bacterial coinfection.

ASPs can assist with interpretation of polymerase chain reaction–based test results and help guide appropriate antimicrobial use in COVID-19 patients.

STRENGTHENING MULTIDISCIPLINARY WORKING RELATIONSHIPS

Initially, ASPs were charged with assuming the burden of the COVID-19 response. A Twitter poll surveying the infectious diseases community and ASPs noted that 30% of respondents were directly involved with the COVID-19 response in their health systems.¹⁷

Additionally, Mazdeyasna et al provided an outline based on traditional ASPs and the extra responsibilities a program might assume in response to COVID-19.¹⁸ These include creating COVID-19 guidelines, expanding prior authorization restrictions to drugs with mixed evidence (eg, ivermectin and lopinavir/ritonavir), and providing education on the constantly changing recommendations.¹⁸ The authors mention that ASPs also have an opportunity to assist with disaster response and preparedness against emerging pathogens by collaborating with infection control.¹⁸ However, there is still a paucity of data regarding how the multidisciplinary working relationship among ID specialists, ASP, and other departments has grown in response to COVID-19.

Specifically, at Loma Linda University Medical Center in California, the multidisciplinary working relationship has expanded between the ID specialists, especially ASP specialists, and various groups. Due to the unique experimental nature of many COVID-19 therapeutics, the ID pharmacists have strengthened their working relationship with the investigational drug pharmacists. The ASP specialists took ownership to review data regarding treatment and creation of inpatient COVID-19 guidelines. Drugs that were previously used to treat rheumatological diseases were repurposed to treat patients who were critically ill with COVID-19. ASP specialists worked closely with the critical-care physician group to create stringent guidelines for the appropriate use of these agents. When new oral antivirals were granted emergency use authorization, prompt collaboration between the ASP and information technology ensued to create order sets and note templates. Additionally, ASP specialists also collaborated with outpatient providers, including emergency department and ambulatory care providers, to ensure proper use and equitable allocation of new antivirals.

CONCLUSION

Reflecting on the impact of the COVID-19 pandemic on HCPs and ASPs, both negative and positive aspects can be felt. The burnout experience shared by many HCPs is an ongoing issue that needs further research to not only address the limited number of solutions, but also techniques to effectively employ those solutions. Additionally, the long-term impact of the initial overutilization of antimicrobials on the development of future antimicrobial resistance is yet to be determined. However, there has been renewed appreciation for ID specialists, especially ASP specialists, and their unique skill set, which has enabled them to navigate the ever-changing landscape of COVID-19 management. Ultimately, COVID-19 has united multidisciplinary groups in this shared experience and laid the foundation to better equip the health care workforce for future pandemics.

References

1. WHO coronavirus (COVID-19) dashboard. World Health Organization. Updated April 12, 2022. https://covid19.who.int/
2. Penwell-Waines L, Ward W, Kirkpatrick H, Smith P, Abouljoud M. Perspectives on healthcare provider well-being: looking back, moving forward. J Clin Psychol Med Settings. 208;25(3):295-304. doi:10.1007/s10880-018-9541-3
3. Ferry AV, Wereski R, Strachan FE, Mills NL. Predictors of UK healthcare worker burnout during the COVID-19 pandemic. QJM. 2021;114(6):374-380. doi:10.1093/qjmed/hcab065
4. Matsuo T, Kobayashi D, Taki F, et al. Prevalence of health care worker burnout during the coronavirus disease 2019 (COVID-19) pandemic in Japan. JAMA Netw Open. 2020;3(8):e2017271. doi:10.1001/jamanetworkopen.2020.17271
5. Zhu Z, Xu S, Wang H, et al. COVID-19 in Wuhan: sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers.EClinicalMedicine. 2020;24:100443. doi:10.1016/j.eclinm.2020.100443
6. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976
7. Support for public health workers and health professionals. CDC. Updated December 2, 2021. https://www.cdc.gov/mentalhealth/stress-coping/healthcare-workers-first-responders/index.html
8. Langford BJ, So M, Leung V, et al. Predictors and microbiology of respiratory and bloodstream bacterial infection in patients with COVID-19: living rapid review update and meta-regression. Clin Microbiol Infect. 2022;28(4):491-501. doi:10.1016/j.cmi.2021.11.008
9. Musuuza JS, Watson L, Parmasad V, Putman-Buehler N, Christensen L, Safdar N. Prevalence and outcomes of co-infection and superinfection with SARS-CoV-2 and other pathogens: a systematic review and meta-analysis. PLoS One. 2021;16(5):e0251170. doi:10.1371/journal.pone.0251170
10. Sieswerda E, de Boer MGJ, Bonten MMJ, et al. Recommendations for antibacterial therapy in adults with COVID-19 - an evidence based guideline. Clin Microbiol Infect. 2021;27(1):61-66. doi:10.1016/j.cmi.2020.09.041
11. Clancy CJ, Nguyen MH. Coronavirus disease 2019, superinfections, and antimicrobial development: what can we expect? Clin Infect Dis. 2020;71(10):2736-2743. doi:10.1093/cid/ciaa524
12. COVID–19 resources. Society of Infectious Diseases Pharmacists. Accessed February 17, 2022. https://sidp.org/covid19
13. Pettit NN, Nguyen CT, Lew AK, et al. Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission. BMC Infect Dis. 2021;21(1):516. doi:10.1186/s12879-021-06219-z
14. Maataoui N, Chemali L, Patrier J, et al. Impact of rapid multiplex PCR on management of antibiotic therapy in COVID-19-positive patients hospitalized in intensive care unit. Eur J Clin Microbiol Infect Dis. 2021;40(10):2227-2234. doi:10.1007/s10096-021-04213-6
15. Foschi C, Zignoli A, Gaibani P, et al. Respiratory bacterial co-infections in intensive care unit-hospitalized COVID-19 patients: conventional culture vs BioFire FilmArray pneumonia plus panel. J Microbiol Methods. 2021;186:106259. doi:10.1016/j.mimet.2021.106259
16. Kolenda C, Ranc AG, Boisset S, et al. Assessment of respiratory bacterial coinfections among severe acute respiratory syndrome coronavirus 2-positive patients hospitalized in intensive care units using conventional culture and BioFire, FilmArray pneumonia panel plus assay. Open Forum Infect Dis. 2020;7(11):ofaa484. doi:10.1093/ofid/ofaa484
17. Stevens MP, Patel PJ, Nori P. (2020). Involving antimicrobial stewardship programs in COVID-19 response efforts: all hands on deck. Infect Control Hosp Epidemiol. 2020;41(6):744-745. doi:10.1017/ice.2020.69
18. Mazdeyasna H, Nori P, Patel P, et al. Antimicrobial stewardship at the core of COVID-19 response efforts: implications for sustaining and building programs. Curr Infect Dis Rep. 2020;22(9):23. doi:10.1007/s11908-020-00734-x