Table 2.

Selected free-text reports by countries according to topic area and income level

Topic	Income level	Selected illustrative quotations
Funding for AMR activities	low	“Previously, there was a small fund from the WHO country office, but during the COVID-19 pandemic, all funding and activities for AMR stopped till now…During the last 10 months, all focus is on COVID-19 and there is no support for AMR by governments and non-governmental organizations.”
	lower middle	“AMR surveillance activities for national and local levels moderately decreased due to the large amount of funding allocated to laboratory services and treatment for covid-19 patients.”
	upper middle	“There was no funding for AMR surveillance at the national level before the pandemic.”
	high	“Indirectly, we may conclude that there is a decrease in AMR support as most microbiologists and epidemiologists were mobilized for COVID diagnostics.”
Partnerships and oversight for AMR activities	low	“Due to the mobility restrictions, activities focused on AMR stopped. Sometimes, we try to use distanced calls but no success. Internet connection is very limited in the country, it was difficult to reach each site [sic].”
	lower middle	“The WHO country office had requested a consultant to support our efforts to develop the AMR master plan, but due to the COVID-19 outbreak, all those plans failed [sic].” “COVID-19 has created platforms for new partnerships and collaborations because of the link in Infection Prevention interventions, e.g. Water and Sanitation and Hygiene (WASH).”
	upper middle	“The COVID-19 pandemic crisis and the issuance of some strict measures to confront the Corona epidemic, including the imposition of a complete curfew, led to poor communication with partners.”
	high	“More people and organisations have found each other, more possibilities regarding data exchange.”
Diagnostics and laboratory testing for AMR	low	“The schedules which had been made to train staff were stalled by the COVID-19 Pandemic. Laboratory turnaround time rose due to less staff levels than usual on the microbiology benches [sic].”
	lower middle	“The laboratory network was strengthened in [our country] as part of the COVID-19 response and this will positively impact the AMR surveillance network. The decision makers are now very sensitized to labs issues [sic].”
	upper middle	“Patients avoided visiting hospitals as they were afraid to be in close contact to the healthcare personnel and inpatients. This resulted in a decrease of patient visits and microbiological orders [sic].”
	high	“Diagnostic pathology activity in microbiology laboratories…has declined when compared with the steep rise in testing work associated with detection of SARS-COV-2.” “Whole genome sequencing (WGS) activity on antibiotic resistance strains has decreased because of the availability of WGS machines (reserved for Covid), of molecular reagents and of staff (half team and staff rotation) [sic].”
Laboratory supplies and equipment for AMR activities	low	“Because there has been a drop in samples being analysed and patients seen facilities, this has caused a reduction in the amount of resources spent on supplies and consumables [sic].”
	lower middle	“There was no impact of COVID-19 on laboratory supplies and equipment for AMR activities as there was no functional surveillance during the COVID-19 pandemic.”
	upper middle	“During Covid-19 lock out, we had many difficulties to import reagents, equipment and some parts in order to repair the equipment [sic].”
	high	“There was some impact on nucleic acid amplification-related work rather than standard culture and antimicrobial susceptibility testing. Assays detecting resistance genes via nucleic acid amplification were in some cases delayed due to the availability of PCR platforms which were in use mostly for SARS-COV-2 RNA detection.”
Availability of staff responsible for AMR activities	low	“Human resources has been one of the areas affected due to covid-19 responses, a lot of staff have been pulled to support covid-19 and this leads to no activities and actions done.”
	lower middle	“In general, most of health staff (doctors, nurses, lab staff, etc.) were called to respond activities of Covid-19 emergency, affecting the availability of these professionals for AMR activities [sic].”
	upper middle	“We had a 2 [moderate impact] in the availability of health professionals in several places and a great increase in the need for professionals during the beginning of the pandemic. Thus, the government supported the hiring of professionals through a specific program that identified non-employed professionals, created a national register of professionals and local demand, and then allocated these professionals where they were most needed.”
	high	“Public health colleagues have been under enormous strain throughout 2020 dealing with the ongoing pandemic. In hospitals, particularly those with small teams, the same core group of staff would traditionally deal with AMR response, stewardship and IPC activities and the added demands of COVID-19 disproportionately affects the capacity of those teams to deal with AMR and stewardship. The increased focus on environmental hygiene throughout the pandemic has likely impacted positively on cleaning. Laboratory scientific staffing resources are already very stretched and the added demands of COVID-19 pandemic on staffing has made it even more challenging to recruit [sic].”
AMR data information systems	low	“The biggest problem is that data are not generated as before and with the special focus on covid, dissemination platforms for data are not available and people are not paying attention to other data sets, but only covid.”
	lower middle	“We have a National AMR database where AMR data are stored, so no changes were experienced [sic].”
	upper middle	“Hospital administration initiated planning to prevent delayed reporting [sic].”
	high	“A laboratory-based surveillance system, originally implemented for AMR surveillance, was adapted to also capture data on SARS-CoV-2 testing and allow for the analysis of co-infections [sic].”
Patient-case mix	low	“Non-urgent hospital visits and elective surgeries decreased due to the COVID-19 scare…Hospital bed occupancy and intensive care unit admission moderately increased due to COVID-19 positive cases being held for two weeks under observation. On the other end, chronically ill cases were avoiding contact with the COVID-19 situations in the hospitals [sic].”
	lower middle	“Reduction or even stopping non-emergency hospital activities (non-urgent and elective surgical procedures) during confinement. Number of ICU beds increased in some hospitals.”
	upper middle	“We have reorganized health services. Some started to serve only COVID-19…In addition, the understanding at the beginning of the pandemic that you should only k care in case of breathing difficulties generated a low demand for emergency care.”
	high	“Preventive measures have been taken to reduce COVID-19 transmission such as the diversion to virtual clinics and phone consultation mainly for outpatients, delivery of medicine to homes, reducing the stay in the hospital and discharging of the patients if the clinical condition is ok, postponing the elective surgeries and working mainly on the emergency procedures and surgeries [sic].”
IPC measures	low	“All people and at every work station were observing hand hygiene, social distancing, alcohol hand rub, and mask wearing which positively controls spread of antimicrobial resistant organisms [sic].”
	lower middle	“Our various hospital structures took advantage of this situation to strengthen their IPC activities (particularly awareness, training).”
	upper middle	“Several campaigns have been held including WASH awareness campaigns.” “Training is not possible due to strict social distancing. Virtual meetings are not practical if the IT system is not well supported [sic].”
	high	“IPC staff was overworked by COVID-19 and IPC training was performed by peers (by peers and IPC link nurses).” “COVID-19 has revealed the need to integrate infection prevention and control across the entire healthcare delivery system. This needed response includes strategies for implementation across all levels of care, use of data for targeted action, tailored tools and strategies for early detection and management, effective ongoing communication and education, strong connection between public health and healthcare, policies for accountability and sustainability, and an ongoing commitment to these improvements.”
Antibiotic consumption	low	“Due to the fever and other presenting symptoms of COVID-19, patients try to do self-medication and doctors also prescribe antibiotics empirically since the infecting agent was not able to be cultured then.”
	lower middle	“Consumption of WHO watch and reserve antibiotics increased because in rural facilities where diagnostic tools for COVID-19 are scarce, the use of antibiotics for pneumonia-like symptoms increased and in urban facilities, the use of azithromycin is still frequent [sic].”
	upper middle	“For large hospitals, there was no impact. For smaller hospitals, moderate decrease was observed due to decreasing patient numbers [sic].”
	high	“Preliminary data show slight increase in March/April in watch antibiotics (such as azithromycin/carbapenems) in inpatient settings [sic].” “We will look at this in more detail, but good data are not yet available.”
AMR rates	low	“Each infection with pathogens avoidable by hygiene for us decreased.”
	lower middle	“It’s too early to comment on impact of increase in use of antimicrobials on AMR during the pandemic, we may have better idea of the impact on AMR trends over the next couple of years.”
	upper middle	“For large hospitals, there was no impact. For smaller, a moderate decrease was observed due to decreasing patient number [sic].”
	high	“The national 2020 antibiotic resistance data will be available only next year, so it is too early to assess the impact of COVID-19 on AMR rates. However, the impression is that MDR isolates are more frequent in ICUs caring for COVID patients. Also, decreased sampling in COVID ICUs, due to the lack of personnel may contribute to underestimating the problem of MDR.”
Long-term perspectives	low	“If no concerted work is not done to control the spread of AMR it will be another pandemic to hit the world.”
	lower middle	“We need to balance AMR and COVID response activities.”
	upper middle	“We need to harness the potential of virtual and remote working methods, this will allow us to reach a larger audience with regard to training of stewardship committee members and health facility workers in their management and surveillance of AMR.”
	high	“We need to support greater resiliency in antibiotic resistance and antibiotic use programs in healthcare and public health. Because, without this resiliency, critical AR work will not happen as new threats emerge.” “It is important that pauses in AMR and HCAI surveillance and stewardship activities are short-term and that experienced staff are supported to resume these activities through recruitment of additional staff for pandemic-related work and investment in infrastructures that facilitate efficient ways of working and acknowledge remote working requirements, e.g. electronic prescribing, surveillance systems.”