Start Smart, Then Focus: Antimicrobial Stewardship Practice at One NHS Foundation Trust in England Before and During the COVID-19 Pandemic
Authors: Elshenawy Rasha Abdelsalam , Umaru Nkiruka , Aslanpour Zoe 
Published: June 2023

ABSTRACTBackgroundAntimicrobial Resistance (AMR), a major global public health threat causing 1.2 million deaths, calls for immediate action. Antimicrobial stewardship (AMS) promotes judicious antibiotic use, but the COVID-19 pandemic increased AMR by 15%. Our study evaluated AMS implementation and inappropriate antibiotic prescribing before-the-pandemic (PD) and during-the-pandemic (DP).MethodsThis retrospective study examined medical records of adult patients (age 25 and above) admitted to an NHS Foundation Trust in England for respiratory tract infections (RTIs) or pneumonia in 2019 and 2020. Our objective was to evaluate antibiotic prescribing practices BP and DP in 2019 and 2020. Primary outcomes included evaluating the prevalence of inappropriate antibiotic prescribing and assessing the implementation of AMS using Public Health England’s ‘Start Smart, Then Focus’ (SSTF) toolkit. Reliable data extraction was ensured by two independent reviewers using a validated data extraction tool.ResultsA total of 640 patient records (320 from 2019 and 320 from 2020) were analysed. The mean age of enrolled adults was 74.3 years in 2019 and 76.2 years in 2020. COVID pneumonia showed a significantly higher odds ratio (OR) of 20.24 (95% CI 5.82 to 128.19, p-value<0.001). Inappropriate antibiotic prescribing, as per local guidelines, increased from 36% in 2019 to 64% in 2020 for the second course of antibiotics DP. Differences were observed in AMS interventions, with an OR of 3.36 (95% CI 1.30-9.25, p=0.015) for ‘Continue Antibiotics’ and an OR of 2.77 (95% CI 1.37-5.70, p=0.005) for ‘De-escalation’.ConclusionThe COVID-19 pandemic significantly impacted antibiotic prescribing, increasing inappropriate use and posing risks of antimicrobial resistance. Factors influencing prescribing practices must be considered, and proactive measures, including updating the SSTF toolkit and developing an AMS roadmap, are needed to address the challenges of AMR in the context of evolving infectious diseases.KEY MESSAGESWHAT IS ALREADY KNOWN ON THIS TOPIC⇒ AMR is a major global health threat, called a silent pandemic, with the potential for 10 million annual deaths by 2050, equivalent to one death every three seconds.⇒ Antimicrobial stewardship (AMS), promoting judicious antibiotic use, plays a pivotal role in combating AMR.⇒ The COVID-19 pandemic led to a 15% rise in AMR and hospital-associated deaths during 2020.WHAT THIS STUDY ADDS⇒ Evaluated the implementation of AMS before and during the COVID-19 pandemic in 2019 and 2020 across four seasonal time points.⇒ Estimated the prevalence of inappropriate antibiotic prescribing in 2019 and 2020.⇒ Identified factors influencing antibiotic prescribing upon admission and during the hospital stay.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE AND/OR POLICY⇒ Our study offered a comprehensive analysis of AMS implementation and identified the key factors that influence antibiotic prescribing and AMS application BP and DP. This critical understanding will be instrumental in shaping a strategic plan intended to improve antibiotic prescribing practices in acute care settings, thereby directing necessary updates and revisions in current policies.