Antimicrobial stewardship before and during the COVID-19 pandemic

In a blog for World Antimicrobial Awareness Week, Rasha Abdelsalam Elshenawy, Dr Nikkie Umaru, and Dr Zoe Aslanpour discuss their study, registered with the ISRCTN registry, investigating the factors affecting the Antimicrobial Stewardship (AMS) implementation in two acute care settings before and during the COVID-19 pandemic.

A Possible Solution for Antimicrobial Resistance

In a blog for World Antimicrobial Awareness Week, Rasha Abdelsalam Elshenawy, Dr Nikkie Umaru, and Dr Zoe Aslanpour discuss their study investigating the factors affecting the Antimicrobial Stewardship (AMS) implementation in acute care settings before and during the COVID-19 pandemic. This study has been registered with the ISRCTN registry and aims to improve appropriate antibiotic use for patients whilst in hospitals.

Antimicrobial Resistance and Stewardship Role

Antimicrobial resistance (AMR) is a global crisis that is likely to continue for the foreseeable future. In 2019, The Lancet reported the estimated global deaths from AMR to be 1.2 million. People are dying from common and previously treatable infections due to bacteria developing resistance to the common antibiotics used in their treatment. If the antibiotic is prescribed inappropriately, not only it does not benefit the patient, but also it could potentially cause side effects for them, such as allergic reactions and toxicity that affects their organs. In recent years, excessive and inappropriate use of antibiotics means they are becoming less effective against serious infections.

The WHO World Antimicrobial Awareness Week is part of a global action plan to raise awareness and take action against the growing issue of AMR. The theme for World Antimicrobial Awareness Week in 2022 is “Preventing Antimicrobial Resistance Together”, and calls upon the general public, health workers, and policymakers to work together to use antimicrobials prudently and to take action to prevent AMR.

Antimicrobial Stewardship is a set of activities that aims to promote the effective and appropriate use of antibiotics. We must be responsible stewards of antibiotics and be antibiotic-aware to preserve their efficacy and protect patients of today and tomorrow from the AMR threat.

COVID-19 and Antimicrobial Resistance

COVID-19 pandemic and antimicrobial resistance (AMR) silent pandemic. Photo credit Rasha Abdelsalam Elshenawy

In June 2022, the global estimate for the number of deaths from COVID-19 was about 6 million, 10% of the worldwide deaths of 60 million. When COVID-19 cases were admitted to hospitals, antibiotics were frequently started. Several studies have also shown that patients with COVID-19 were rarely infected with bacteria when admitted. During the COVID-19 pandemic, many bacterial infections went potentially undiagnosed and untreated. The COVID-19 pandemic has taught us hard lessons and reminded us that AMS is the best way to prevent a looming AMR silent pandemic.

Co-design Research

This research project, registered with ISRCTN, will explore the AMS implementation in Bedfordshire NHS Foundation Trust, before and during COVID-19. It includes three sequential studies.

The First Study: Systematic Literature Review Study

A systematic literature review was conducted in 2021 and aimed to explore AMS interventions before and during the COVID-19 pandemic. It shows promising outcomes in selecting the relevant AMS implementation strategies in acute-care settings. 

The importance of the study findings:

  • Collaboration among healthcare professionals in implementing AMS shows a significant outcome in AMS intervention during the pandemic, such as clinical practice guidelines, AMS multidisciplinary team, and education.
  • Selection for the relevant AMS strategy results in maintaining the appropriate use of antibiotics and achieving action plan goals, such as the UK 5-year action plan of reducing antimicrobial use by 15% by 2024.
  • Novel AMS measures provide a promising effect on AMS, such as using procalcitonin for antibiotic stewardship and the innovative use of technology.
  • There is a need to standardise systems for measuring the outcome of AMS, as this will allow a better comparison, benchmarking, and effective planning of AMS intervention.
  • During a crisis, or emergency, such as the COVID-19 pandemic, antibiotics appeared to be over-used with hospitalised people. An organisational action plan for AMS implementation should be established to prepare for any future emergencies.
  • The reliability of country-specific AMS, such as the UK Health Security Agency (UKHSA) country-level AMR indicators, showed more promising outcomes than the individual AMS strategies, such as prior authorisation and de-escalation.

The Second Study: Retrospective Observational Study 

This study will investigate the AMS implementation in Bedfordshire Hospitals NHS Foundation Trust before and during the COVID-19 pandemic.

The Third Study: Cross-Sectional Study

This study will explore the knowledge, attitudes, and perceptions of healthcare professionals, such as doctors, pharmacists, and nurses, toward antibiotic prescribing and factors affecting the AMS implementation at Bedfordshire Hospitals NHS Trust before and during the pandemic.

Antimicrobial Stewardship implementation before and during COVID-19. Photo credit Rasha Abdelsalam Elshenawy

In conclusion, we must stay focused on preparing for any unknown emerging threats in the future, whenever and wherever it emerges. The output of this research project will provide considerable potential for impact in reducing AMR.

This research project is sponsored by the University of Hertfordshire (UH). Ethics approval has been granted by the Health Research Authority under reference 314805. If you want to learn more about this project, visit the research project website, or please get in touch with Rasha Abdelsalam Elshenawy, Principal Research Investigator, Department of Pharmaceutical Science, University of Hertfordshire School of Life and Medical Science, at

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