An audit on adherence to antimicrobial prescribing guidelines during Wave One of the SARS-CoV-2 pandemic.

In December 2019, Wuhan, China became the centre of an outbreak of pneumonia of unknown cause, later designated coronavirus disease 2019 (COVID-19), due to isolation of a novel coronavirus from these individuals: SARS-CoV-2 [1].

This particular strain showed marked virulence and mortality, being declared a global pandemic in March 2020. The clinical spectrum is broad, encompassing asymptomatic infection, isolated pyrexia, gastrointestinal distress, mild respiratory tract illness and severe viral pneumonia with respiratory failure and even death [2].

Although antibacterial agents have no activity against coronavirus infections, initial recommendations suggested prescribing certain antibacterials pre-emptively to prevent or treat concurrent bacterial infections [3]. If considered, a β-lactam providing coverage for Streptococcus pneumoniae and meticillin-susceptible Staphylococcus aureus should be employed. Once-daily or continuous administration was preferred to decrease the use of personal protective equipment and to minimize exposure risk as per recommendations by the Irish Health Protection Surveillance Centre [4,5].

It is with this recommendation in mind that usage of intravenous ceftriaxone became popular – both for its broad coverage for community-acquired pneumonia and its once-daily administration [6]. However, once SARS-CoV-2 ribonucleic acid (RNA) was ‘not detected’ in diagnostic specimens, ceftriaxone was no longer deemed appropriate, as risks associated with multiple daily dosing no longer applied. Diagnoses should have been reviewed and a more focused approach to antibiotic prescribing adopted, as reflected in national guidelines [4,5].

Our study aimed to assess adherence to antibacterial prescribing guidelines at our institution during the first wave of this pandemic for medical patients admitted along our COVID-19 pathway via a retrospective chart review.

To be assessed via the COVID-19 pathway, patients would have presented with symptoms allowing COVID-19 to be included among differential diagnoses. Initial clinical impression and antibacterial prescriptions were noted from both the emergency department and admitting medical teams, together with revised diagnoses and alterations in therapy following the results of SARS-CoV-2 polymerase chain reaction tests. Whether or not these changes were in line with local prescribing guidelines was documented [4,5].

The results of this initial assessment, Phase One (May 15th–29th, 2020), were communicated to all relevant stakeholders, namely consultant and non-consultant hospital doctors working the COVID-19 pathway, via small-group socially distanced teaching sessions and technological correspondence through electronic mails and restricted social media groups. The study was then repeated two weeks later: Phase Two (June 13th–26th, 2020).

In total, 85 and 87 adult medical patients were admitted throughout Phase One and Phase Two of the audit cycle respectively. Compliance to national and local prescribing guidelines was found to be 95% for both phases of initial assessments, at which point COVID-19 remained a differential diagnosis. Following review of prescription drug charts of patients where SARS-CoV-2 RNA was ‘not detected’, compliance was reduced to 72.9% during Phase One of the audit due to lack of tailoring antibacterial therapy. Certain antibacterial agents, namely ceftriaxone, continued to be prescribed when they were no longer deemed appropriate.

Phase Two of the audit saw a marked improvement to 90.8% compliance in this regard, with an overall decrease in ceftriaxone prescriptions: 81 to 42 by emergency department and 42 to 29 by medical teams over the two-week period.

Further trends in antibacterial prescriptions are shown in Figure 1 .

Figure 1

Trend in antibacterial prescribing over the audit cycle. ED, emergency department.

During the first wave of this pandemic, there was an increase in broad-spectrum antibacterial use in our institution in patients being admitted with suspected COVID-19. Had this continued without indication, patients would have been at increased risk for adverse effects such as C. difficile infection in addition to the emergence of antimicrobial resistance (AMR) [6,7].

We addressed this issue through the use of this audit with timely feedback to prescribers via small-group teaching sessions, electronic mail, and other telecommunication platforms. These interventions resulted in an increase in compliance with our prescribing guidelines during the second phase of this audit with a corresponding decrease in ceftriaxone prescriptions.

Encouraging the use of prescribing guidelines and the adoption of the ‘Start Smart, Then Focus’ approach is a key element of hospital antimicrobial stewardship (AMS) programmes. We have continued to use these methods to communicate audit results to prescribers and have found that timely and specific feedback has led to greater engagement with the hospital AMS team.

The SARS-CoV-2 pandemic has dominated every aspect of global health in the past two years, putting other longer-term public health problems on the back burner. Yet, looking to a time after COVID-19, challenges such as antimicrobial resistance will persist and may potentially be exacerbated by the current pandemic [6].

Conflict of interest statement

None declared.

Funding sources

None.