Table 1.

Potential impacts of healthcare system adaption during the COVID-19 pandemic on antimicrobial resistance

Affected area	Potential impact	Potential interventions
Increased focus on hand hygiene in hospitals	Reduction in the spread of AMR within healthcare settings	Ensure adequate resources and equipment available to support increase in demand (e.g. hand sanitizer)
		Ensure that routine surveillance systems remain in place to monitor rates of AMR within healthcare settings
Social distancing in the community	Reduction in antimicrobial- seeking behaviours by members of the public, leading to reductions in antimicrobial prescribing	Reinforcement through public engagement
Less opportunity for isolation of infectious/MDRO patients	Potential spread of MDRO	Hand hygiene and barrier nursing
	Potential for suboptimal management of other public health challenges (e.g. TB)	Sustaining MDRO surveillance
		Staff and patient education and training
		Clustered cohorting of patients by risk factor (e.g. COVID-19 and CPE; COVID-19 and MRSA)
Pre-emptive discharge of patients and cancellation of routine procedures to enhance bed capacity	Reduction in patients carrying MDRO, such as CPE, within the hospital environment	Stringent surveillance systems to detect and track the spread of AMR on reintroduction of these patients to healthcare services
Diversion of all PPE for SARS-CoV-2 patients	Potential spread of MDRO	Hand hygiene and barrier nursing
		Sustaining MDRO surveillance
		Staff and patient education and training
		Appropriate stratification of PPE for different indications in line with evidence-based guidelines
Increased rates of empirical antimicrobial therapy for patients presenting with respiratory symptoms	Potentiation of AMR	Clear guidelines for empirical therapy in suspected SARS-CoV-2 patients, specifically delineating the requirement for anti-pseudomonal and/or atypical coverage
		Education and emphasis on local stewardship within all healthcare workers
		Re-establishment of AMS oversight as soon as possible
		Upskilling of staff within the organization (e.g. nurses and pharmacy technicians) to take on broader roles and responsibilities
		Development of rapid diagnostics to support prescribing decisions, including a clear role for the use of procalcitonin to detect bacterial infection
		Ensuring that pandemic preparedness is part of future IPC and AMS strategy
Increased rate of telemedicine within primary and secondary care and outpatient services	Possible increase in community rates of antimicrobial prescribing as part of safety-netting	Need for education and specialist support to develop AMS strategies for telemedicine
	Possible reduction in community antimicrobial prescriptions due to social distancing and reduced access to pharmacies	Engagement with community-based pharmacies, who may not be confident in screening secondary care medicines
		Need for development in technology to support risk stratification
Redeployment of antimicrobial stewardship teams to deal with healthcare strain due to pandemic	Loss of developed stewardship frameworks within local healthcare environments	Focus on education and responsibility of individual teams for promotion of appropriate antimicrobial usage
		Addressing current social hierarchies within healthcare and upskilling of staff within the organization (e.g. nurses and pharmacy technicians) to provide routine AMS services
		Integration of AMS/IPC teams
Maintenance of institutional memory and team dynamics within organizations experiencing rapid reorganization and recruitment of staff	Loss of best practice and leadership within local team environments	Education and training
		Focus on fostering positive behaviours towards antimicrobials and infection control
		Ensuring that structures are agile enough to absorb new individuals with minimal impact of process and patient care
Overcrowding associated with overloading of healthcare systems	Major driver for the transmission of AMR	Stringent surveillance systems to detect and track the spread of AMR
		Ensuring that routine MDRO screening still takes place in the face of increased viral screening
		Cohorting of high-risk patients
		Contingency plans for rapidly responding to detected outbreaks
Depletion of structural resources	Loss of side-room capacity leading to propagation of SARS-CoV-2 infection due to cohorting of positive and negative patients	Stringent pathways for segregation of cases
		Rapid diagnostics to facilitate rapid identification

AMS, antimicrobial stewardship; IPC, infection prevention and control.