The emergence of the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has required an unprecedented response to control the spread of the infection and protect the most vulnerable within society. Whilst the pandemic has focused society on the threat of emerging infections and hand hygiene, certain infection control and antimicrobial stewardship policies may have to be relaxed. It is unclear whether the unintended consequences of these changes will have a net-positive or -negative impact on rates of antimicrobial resistance. Whilst the urgent focus must be on controlling this pandemic, sustained efforts to address the longer-term global threat of antimicrobial resistance should not be overlooked.
The emergence of, and subsequent pandemic caused by, the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has placed an immense strain on healthcare systems. 1, 2 This has required unprecedented responses to control the spread of infection and protect the most vulnerable.
In response to the pandemic, healthcare systems have rapidly adapted infection control policies to ensure adequate capacity to isolate patients with potential SARS-CoV-2 infection. Societal focus on the threat from this emerging infectious disease has driven a heightened awareness of the importance of personal hygiene, particularly hand hygiene, environmental contamination and increased use of personal protective equipment (PPE). However, the pandemic is also likely to require the relaxing of measures that prevent the spread of MDR organisms (MDRO), such as screening, isolation in single rooms and antimicrobial stewardship.
The paucity of available data makes it difficult to predict the impact that this pandemic may have on antimicrobial stewardship programmes and long-term rates of antimicrobial resistance (AMR). On one hand, the increased focus on hand hygiene, attempts to limit patient contact and social distancing may lead to reductions in healthcare-associated transmission of disease. On the other hand, the prioritized allocation of isolation rooms to COVID-19 patients, cohorting and/or management in open bays of patients colonized with carbapenemase-producing Enterobacteriaceae (CPE)/VRE/MRSA/Clostridioides difficile and the inevitable higher workload of healthcare workers may potentially lead to a greater number of hospital transmissions.
The potential propagation of AMR may also be exacerbated by increasing rates of antimicrobial prescribing and potential breakdowns in well-established stewardship programmes. For example, despite few reports of bacterial coinfection, 62% of patients with COVID-19 had received antimicrobial therapy in a recent International Severe Acute Respiratory and Emerging Infections Consortium (ISARIC) report. 3 These prescriptions tended to be broad spectrum in nature. 4 In addition to excessive and inappropriate antimicrobial prescribing, the spread of other pathogens and MDROs may also be affected by day-to-day practicalities of an emergency focus on a single primary pathogen, which may affect the depth of sampling for other organisms. The redeployment of antimicrobial stewardship teams and laboratory capacity to support the workload associated with SARS-CoV-2 is likely to compound this further.
With predictions that the current pandemic could continue to consume the focus of individual national healthcare systems such as those in the UK and the USA for up to 18 months, 5 urgent analysis of its impact on AMR is required. This will support the development of contingency interventions to mitigate the potential impact of the pandemic on rates and transmission of AMR. Learning early lessons from countries currently affected will be important in supporting evidence-based guidance for those regions not yet burdened by an exponential rise in COVID-19 cases. In particular, the unintended consequences, whether positive or negative, of these health-system changes need to be described and where negative impacts are identified these must be mitigated V C The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For permissions, please email: journals.permissions@oup.com. For debate against to ensure that efforts to address the long-term and devastating threat of AMR are sustained. Table 1 outlines some of the core antimicrobial stewardship efforts affected by the SARS-CoV-2 pandemic, suggesting potential interventions to help mitigate the impact of the pandemic response on AMR.
With the rapid redeployment of side rooms and PPE to protect patients and staff from respiratory viral infections and saturation of any isolation capacity, the ability to adhere to isolation policies normally deployed to prevent the spread of MDROs is likely to be challenged. Whilst increased hand hygiene may help prevent transmission, 6 pragmatic solutions are required to ensure sustained surveillance for MDROs in both SARS-CoV-2-positive andnegative patient cohorts.
The disruption of routine services and redeployment of staff to alternative areas, such as critical care, is likely to cause disruption to embedded antimicrobial stewardship programmes within hospitals. These rely on multidisciplinary support and regular review of practice as part of normal business within hospital team structures. With the requirement for increased infectious disease support in managing the response to the pandemic, stewardship teams may be redeployed from their primary roles, leading to reduced opportunities to optimize antimicrobial therapy in patients. Loss of expert support for antimicrobial decision-making, a paucity of evidence-based guidelines for antimicrobial prescribing in SARS-CoV-2 and anxiety of medical colleagues in front of deteriorating patients may lead to further inappropriate use of antimicrobials. Urgent steps are needed to develop a consensus on the empirical use of antimicrobials, together with clarification on the role of Watch and Reserve agents in the WHO essential medicines AWaRe criteria. 7 To support the redeployment of stewardship teams, leadership must be developed within local teams managing SARS-CoV-2 patients, supported by the development of evidence-based guidelines for the role of diagnostic tests, such as procalcitonin, to inform appropriate empirical treatment.
Institutions must also focus on behavioural factors and team dynamics that will come under immense pressure as healthcare services respond to the increase in demand associated with the pandemic. Team dynamics, fear and specialty-level cultural norms of practice are major drivers of inappropriate antimicrobial prescribing. 8 These factors must rapidly be assessed and stabilized in the face of large variations in staffing levels within healthcare systems in the coming months. This will require effective leadership, clear communication across professions and realignment of chains of command in order to accommodate staff from multiple professions and differing experience. We must learn from existing social science research to be responsive and adaptive to the changing priorities and clinical needs. This cannot be achieved without engagement from across the healthcare multi-professional teams -the very personnel the interventions will target.
The planned implementation of large field-hospitals with a major focus on a primary viral pathogen also presents potential negative drivers for control of AMR. Uncertainty regarding the levels of staffing and support services for such facilities, as well as the pressures of clinical practice and patient culture in such a setting do present opportunities for many relevant MDROs to spread, with or without disease presentation.
In community practice, primary and secondary care has rapidly shifted towards telemedicine. 9 This is a vital step in protecting both healthcare workers and patients, but currently has limited data to support its potential to reduce or propagate suboptimal antimicrobial prescribing and therefore AMR. 10, 11 Limited evidence suggests that telemedicine is associated with increased rates of antimicrobial use. 10, 11 Currently, there is little guidance and support for colleagues practising telemedicine for the management of infection. With primary care being the biggest prescriber of antimicrobials, there is an urgent need for education and training, development of risk stratification and guidance that is specific for telemedicine consultations. Community pharmacy roles must be urgently developed to support appropriate stewardship of antimicrobials prescribed by this route.
In summary, before the outbreak of SARS-CoV-2 in December 2019, major national and international interventions had begun to focus on reducing the potential future impact of AMR on society.
The consequences of the current pandemic have the potential to stretch well into the post-COVID-19 era. With increased societal sensitization towards emerging threats from infectious diseases For debate and the concept of transmission and acquisition of disease, this may subsequently drive greater engagement with the problem of AMR. However, the current pandemic may also have a greater impact on society through the unintended propagation of AMR. Whilst undoubtedly the main focus of healthcare must be on controlling the spread of SARS-CoV-2 and mitigating the immediate impact on individual patients, we must not lose sight of the longer-term threat of AMR if our current structures and stewardship programmes are completely disrupted during this unprecedented time.