for antimicrobial (AM) consumption, AM resistance (AMR) rates and healthcare-associated infections are as yet unknown. Since the diagnosis of the first case of COVID-19 on 29 February 2020 in Ireland, AM stewardship (AMS) teams across the acute hospital sector have adapted to changing work patterns and workloads. The Irish Antimicrobial Resistance and Infection Control (AMRIC) team co-published guidance documents on the antiviral treatment of COVID-19 based on rapid evidence reviews as well as AMS strategies during the pandemic to assist clinicians nationally. 2, 3 We invited healthcare professionals involved in AMS programmes in the acute hospital setting to participate in an electronic survey hosted on SurveyMonkey V R and open for participation from 20 to 25 May 2020. The survey investigated the challenges, if any, the COVID-19 pandemic posed to the effective delivery of AMS with a view to informing interventions to optimize delivery of AMS in the COVID-19 era. Data were collated and analysed on Microsoft Excel V R 2019 and SPSS version 26 and are available in detail in Appendices S1 to S7 (available as Supplementary data at JAC Online).
There were 98 respondents from 45 public and private hospitals in Ireland (45/67, 67%), of which 45% (43/95) were AMS and infectious diseases pharmacists, 26% (25/95) were clinical microbiologists and 11% (10/95) were infectious diseases physicians. Seventy-six percent (65/86) reported that COVID-19 had impacted on the effective implementation of AMS programmes locally with a statistically significant decrease in the median score for the effectiveness of AMS programmes from 7 pre-COVID-19 to 5 during COVID-19 (z = 6.584, P < 0.001). The greatest decline in effectiveness was seen in tertiary and general hospitals, most likely due to increased burden of COVID-19 cases in these healthcare facilities. 4 Table 1 summarizes the unexpected AMS-related occurrences as a result of the pandemic as well as the interventions introduced to circumvent these challenges. The main themes identified related to AM use, MDR organism (MDRO) surveillance, diagnostics, use of experimental agents, medication supply and communication. AMS interventions specific to their COVID-19 patient cohort that were introduced and proved particularly effective during the acute phase of the pandemic included regular treatment guideline review and updates, introduction of biomarkers such as procalcitonin, review of indication of AMs and use of electronic resources. The majority found the national guidance documents, which were updated regularly, extremely useful.
The key challenges to AMS brought about by COVID-19 were mainly due to: the lack of resources as a result of re-allocation to COVID-19 planning and management; the difficulties posed by infection prevention and control (IPC) restrictions and social distancing in delivering ward rounds, performing audits, providing education and holding committee meetings; and increased use of AMs due to the difficulty in diagnosis of secondary infections, particularly in patients with severe COVID-19. These challenges for effective delivery of AMS programmes reflect the concerns expressed by Rawson et al. 1 Our findings suggest that successful delivery of AMS in the COVID-19 era requires further resourcing in three key areas: technology, diagnostics and guideline development. Innovative utilization of information and communication technologies (ICT) facilitated education, AMS meetings, virtual ward rounds and clinics as well as handover meetings. This was most noted in hospitals where electronic prescribing and health records are available. Evidence points to the benefit that ICT can have on AMS programmes in terms of increased productivity, more effective case finding, workflow auditing and optimization of infection management. 5 Furthermore, early literature suggests that electronic healthcare platforms improve the management and review of COVID-19 patients. 6 Consistent with published literature to date, 7 the difficulty in diagnosis of bacterial/fungal coinfections, particularly in patients with severe COVID-19, resulted in reports of increased use of empirical AM treatment and consequently increased risks of Clostridioides difficile infection 8 and emergence of MDRO. Further research into the use of procalcitonin and other biomarkers in the COVID-19 patient cohort to provide diagnostic stewardship is required as these may be useful tools to decrease inappropriate prescribing and support early deescalation of AM therapy. 9, 10 Sustaining MDRO surveillance and compliance with IPC protocols are key areas to focus on going forward. 
Lastly, national guidance documents were extremely beneficial, particularly in hospitals with less AMS resources, which underlines the importance of further similar evidence-based guidance on the treatment of other infections.
Our survey contributes to an evolving literature on the impact of COVID-19 on AMS and interventions to sustain and deliver effective AMS programmes during this time. Further research is required to quantify the unintended consequences for AMR and the success of different AMS strategies and interventions in reducing AMR in the pandemic and post-pandemic environment. 