Abstract
During COVID-19 pandemic, implementing and maintaining an antimicrobial stewardship protocol obtained both low rates of MDR microorganisms and low antimicrobial use in an 800-bed hospital network in northern Italy. Infectious diseases specialist consulting was crucial to maintain this protocol active.
Keywords: infection control, anti-infectives, infectious diseases
In December 2019, the first cases of severe acute respiratory syndrome (COVID-19) caused by a novel coronavirus (SARS-CoV-2) were reported in Wuhan, a region of China. 1 This infectious disease has spread very quickly and has led to the current pandemic affecting the world. At the end of February, the first COVID-19 patient was identified in the province of Lodi, Italy. Since then, Italy is facing one of the worst outbreaks globally, leading to more than 126 000 deaths as of May 31st.
Before this viral pandemic, there was another pandemic called “invisible pandemic” by the World Health Organization (WHO), namely the increase in antimicrobial resistance (AMR) could cause 10 million deaths per year by 2050 if not stopped. 2
Many authors 3 have reported that antimicrobial resistance could increase the deaths during pandemics of bacterial and viral diseases. Multidrug-resistant organisms (MDROs) causing hospital-acquired infections include Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), Carbapenem-resistant Enterobacteriaceae (CRE), multidrug-resistant Acinetobacter baumannii (MDRAB). Infections caused by MDROs result in increased morbidity, mortality, and healthcare costs. 4 Both well-implemented infection control strategies and effective antimicrobial stewardship programs are crucial in preventing nosocomial acquisition of MDROs. 5 In the current COVID-19 pandemic, there is a high likelihood that the pandemic will increase the deaths associated with bacterial MDR and fungal infection.
Although COVID-19 is a viral disease, antibiotics in COVID-19 patients have been common, especially at the beginning of the outbreak. In published series of hospitalized patients with COVID-19, the prevalence of antibiotic use ranges from 72% to 95%. 3 However, many authors show that the prevalence of bacterial coinfection in these patients is low at 8%, and superinfection is at 14.3%. 6 Therefore, the systematic use of antibiotic therapy does not appear to be a rewarding strategy and can lead to adverse reactions or related to AMR. 7 For this reason, our infectious disease (ID) unit continued to follow the antimicrobial stewardship (AMS) program.
To analyze the evolution of consumption within the hospital and compare it with other hospitals, we used the consumption of antibiotics calculated in a defined daily dose (DDD) as an indicator. In our hospital, the consumption of antibiotics in 2019 and 2020 is shown in Table 1.
Table 1.
Comparison of the Consumption of Antibiotics Used for the Treatment of Acquired Pneumonia in 2019 Versus 2020.
| 2019 DDD | 2020 DDD | Total 2019–2020 DDD | |
|---|---|---|---|
| AMOXICILLIN/CLAVULANATE | 7412 | 60 208 | 134 328 |
| CEFTRIAXONE | 1405 | 12,65 | 267 |
| CLARITHROMYICIN | 1044 | 8,27 | 1871 |
| MEROPENEM | 718 | 5,22 | 124 |
| LEVOFLOXACIN | 139 | 1,04 | 243 |
| PIPERACILLIN/TAZOBACTAM | 1053 | 10,94 | 2147 |
| Total DDD | 11 772 | 9832 | 21 604 |
In 2020, antibiotic consumption was lower than in 2019. Many authors show the increase of antibiotic prescription in 2020, in particular in March–April.8-11 In our experience, the mean global consumption of antibiotics used to treat pneumonia during hospitalization was lower in 2020 than in 2019, although no statistically significant (P = 0.2).
From January to December 2020, the most consumed antibiotics were amoxicillin/clavulanic (60 218 DDD), ceftriaxone (12 645 DDD), piperacillin/tazobactam (10 941 DDD). Furthermore, piperacillin/tazobactam is the molecule showing the largest prescribing increase. The overall consumption of antibiotic therapy in 2020 appears to be significantly lower than in 2019 despite the COVID outbreak (98 329 vs 117 717).
In our 800-bed hospitals’ network (Santa Maria Degli Angeli Hospital and Ospedale di San Vito al Tagliamento in Friuli Occidentale, Italy), some microorganisms, considered crucial from an epidemiological and clinical point of view, are identified, monitored, and notified by our microbiologists: MRSA, VRE, β-lactamase an extended-spectrum (ESBL) Enterobacteriaceae and CRE isolations (sentinel microorganisms or alert organisms). Table 2 shows the comparison of these alert organisms in our hospitals in 2019 and 2020. As shown, the general trend is not significantly different despite the pandemic disaster. In particular, the incidence of CRE acquisition decreased from a baseline of 11 cases yearly. There was no transmission of multidrug resistance organism (MDRO) in the hospital during COVID-19, implying correct and proper use of personal protective equipment.
Table 2.
Frequency of Alert Organism Isolations in Our Hospital in the Years 2019 and 2020. The Represented Organisms Correspond to Isolations of Microorganisms in Course of Infection.
| Alert organism | 2019 n (%) | 2020 n (%) |
|---|---|---|
| MRSA | 116 (18.1%) | 99 (19.4%) |
| VRE | 10 | 8 |
| ESBL | 568 (11.7%) | 505 (10.1%) |
| CRE | 11 | 4 |
Although our hospital was at the forefront during this violent epidemic tsunami, we continued to perform with consultation for antimicrobial stewardship for months. Infectious disease consultations increased from 1963 in 2019 to 2774 in 2020, increasing about 30%.
To our knowledge, no formal recommendations exist for the creation of antimicrobial stewardship programs in emergency response preparedness efforts. Our experience shows how adapting the AMS program to the new healthcare reality has allowed concrete management of antibiotic therapy consumption while keeping microorganisms under control. Continuing the Infectious Diseases (ID) consultancy above during the pandemic period allows us to maintain the levels of antibiotic consumption below those observed in the previous year.
In conclusion, the in-hospital strategies implemented during 2020 by the hospital AMS contributed to reducing antibiotic consumption despite the outbreak of the SARS-CoV-2 pandemic. Unlike what happened in the pandemic period globally, ID specialists play a pivotal role in managing hospitalized patients with infection control and AMS.
Footnotes
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Francesco Cugini 
https://orcid.org/0000-0002-5805-9393
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