Report highlights how COVID hindered the fight against antimicrobial resistance

Tired healthcare worker

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A new report from the Department of Health and Human Services (HHS) suggests that a number of interrelated factors hampered the ability of US hospitals to control antimicrobial resistance (AMR) during the COVID-19 pandemic.

Severely ill patients with an increased need for mechanical ventilation. Lengthy hospitals stays and increased caseloads. Fear of undertreatment and lack of clear and timely guidelines. An overburdened healthcare workforce that had to focus much of its energy on COVID patients. Limited supplies of personal protective equipment.

According to the report from HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE), which involved a literature review, stakeholder meetings, and interviews with antimicrobial stewardship program (ASP) physicians and pharmacists in 14 states, these are just a few of the reasons why the COVID-19 pandemic resulted in "large-scale disruption" of US efforts to combat AMR. The impact of the disruption included 15% increases in drug-resistant hospital-acquired infections (HAIs) and AMR-related deaths in the first year of the pandemic compared with pre-pandemic levels.  

The authors of the report say they hope the findings will inform efforts to combat antibiotic overuse and drug-resistant infections in future public health emergencies.

"Reflecting on the experiences and outcomes of the pandemic is valuable for adapting and improving future healthcare practices," they wrote. "Facilities and policymakers should assess what worked, what didn't, and how they can better prepare for future challenges."

'Everyone got antibiotics'

Ultimately, the factors described in the report are all connected to the crush of severely ill patients that descended on hospitals across the country when the COVID-19 pandemic hit in early 2020. According to the report, an estimated 3.6 million COVID-19–related hospitalizations occurred in the United States from May 2020 to April 2021, occupying up to 90% of all available inpatient beds in some hospitals. 

On average, COVID-19 patients were hospitalized for over 14 days, with many undergoing mechanical ventilation—two factors that increased their risk for HAIs. And in the early months of the pandemic, clinicians had few treatments available and were concerned about the potential for bacterial co-infections in their sicker patients. 

As a result, an estimated 80% of hospitalized US COVID-19 patients received antibiotics from March to October 2020, which likely contributed to rising AMR rates. Data reviewed for the report suggest that multidrug-resistant infections were five times more likely to occur in COVID wards than non-COVID wards.

"We didn't know what COVID meant or whether people had coinfections, so everyone got antibiotics and supportive care," one ASP physician said in an interview. "Fear drove us to give everything we could to try to save lives."

An unprecedented time for hospitals

The influx of patients eroded the emotional, mental, and physical health of healthcare workers, leading to staff shortages and burnout. Many healthcare professionals missed work because they contracted COVID, while others left the profession over the stress and demands of the pandemic. Exhausted healthcare workers had to focus on immediate patient care and their own needs, making it difficult to sustain the infection prevention and control (IPC) efforts and ASPs that can keep AMR in check.

"The challenges of the COVID-19 pandemic put intense stress on infection preventionists, ASP staff, and other healthcare providers working to combat AMR," the report states.

We didn't know what COVID meant or whether people had coinfections, so everyone got antibiotics and supportive care.

As the authors note, the pandemic's impact on IPC programs in US hospitals, and how that may have contributed to the rise in drug-resistant HAIs, has been well documented. A 2021 study by the Centers for Disease Control and Prevention (CDC) cited the pandemic's strain on hospital staff as one of the reasons for significant increases in central line–associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated events in 2020.             

"The year 2020 marked an unprecedented time for hospitals, many of which were faced with extraordinary circumstances of increased patient caseload, staffing challenges, and other operational changes that limited the implementation and effectiveness of standard infection prevention practices," the CDC wrote. 

Case reports on AMR-related hospital outbreaks during the pandemic have also cited lapses in IPC protocols. But the ASPE report suggests hospital ASPs were also heavily affected, with some severely scaled back and others stopped completely. 

"We had a 100% suspension of ASP activities," said another ASP physician interviewed for the report. "Everything switched to COVID."

Even at hospitals at which ASPs had strong support and were maintained, physicians and pharmacists had less time for stewardship activities because of increase pandemic-related duties. In addition, ASP staff reported that resource limitations—including limited lab capacity and shortage of sample collection tools—and reliance on virtual communications platforms such as Zoom also thwarted ASP activities. 

Preparedness should include AMR planning

Prior to the pandemic, AMR and HAI rates had been declining in US hospitals, a drop attributed in part to improved IPC strategies and the establishment of ASPs. But the report notes that changes in the patient population and higher AMR rates post-pandemic may require revisiting and adapting their practices. 

"Published literature and stakeholder meeting participants observed that, even in the post-pandemic period, patients remain sicker than before the pandemic," they wrote. "Persistently higher rates of AMR after the pandemic may be related to this shift in the complexity of cases that healthcare systems now need to manage regularly."

If you really want to invest in pandemic preparedness, invest in stewardship.

The authors say, however, that several lessons emerge from the COVID-19 experience that could help US hospitals return to pre-pandemic AMR rates. Among them are the importance of timely access to AMR-related data, guidance, and diagnostics; robust communication channels and relationships; and strong ASP leadership and institutional support for healthcare workers. 

"Better data, communication, resources, and planning can help move us back to pre-pandemic and lower rates of AMR and mitigate the impact of future public health emergencies on AMR," the report concludes.

Another lesson is that preparedness for public health emergencies should include planning for AMR management. Preparation should include integrating core stewardship practices into emergency response plans to ensure they can continue even when resources are stretched. 

"If you really want to invest in pandemic preparedness, invest in stewardship," one ASP physician told the authors. "You can't build these capabilities during a pandemic; they need to be established beforehand."

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