Impact of COVID-19 on antimicrobial stewardship activities in Italy: a region-wide assessment

Abstract

Background: In the region of Piedmont, in Northern Italy, formal monitoring of antimicrobial stewardship (AMS) programs has been in place since 2012. The objective of our study was to provide an updated assessment of AMS programs operating in our region, and to assess the impact of the COVID-19 pandemic on stewardship activities.

Methods: A retrospective observational study was conducted to investigate AMS programs implemented in acute-care trusts participating in a broader healthcare-associated infections and antimicrobial resistance (AMR) prevention and control program, promoted by the regional health department. Within this program, structure, process, and outcome indicators of AMS programs were investigated, using a previously developed scoring system. Differences between scores prior to (2019) and during the pandemic (2021) were assessed. Linear regression was used to assess whether the 5-year trends (2017-2021) in outcome measures in relation to structure and process scores were statistically significant. Compound annual growth rates (CAGR) for each outcome were calculated to illustrate changes in outcome rates over time.

Results: All public trusts in the Region (20) and a small number of private institutions (3) provided data for this study. A modest, non-significant improvement was found for 2021 structure, process, and total scores compared to respective 2019 scores. A significant improvement was found concerning the definition of a formal mission statement, whereas significantly less trusts included monitoring adherence to antimicrobial policy or treatment guidelines in their programs. Overall consumption of antibiotics for systemic use saw an increase in 2021, with 2021 recording the highest median overall consumption compared to all previous years considered in this study. Methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) rates decreased over the 5-year period. Significant downwards trends in MRSA rates were identified for high-outlier structure and process groups.

Conclusions: Results of this study suggest AMS programs in Piedmont were not set back following the pandemic. This outcome was possible thanks to well-established programs, coordinated within a regional framework. Continued efforts should be dedicated to supporting AMS programs and contrasting AMR, even when the focus is shifted towards other public health emergencies.

Keywords: Antimicrobial resistance; Antimicrobial stewardship; Antimicrobial usage; COVID-19; Italy; Pandemic; Quality improvement; Quality indicators.

Fig. 1

Box plots depicting structure, process and total scores assessed through quality indicators for the evaluation of antimicrobial stewardship (AMS) programs operating in the region of Piedmont, Northern Italy, 2019 vs. 2021 (N = 25 and N = 23 respectively)

Fig. 2

Outcome measures of trusts participating in the study stratified by year, Piedmont, Northern Italy, 2017-2021. a. Alcohol-based handrub, N=23. b. Antibacterials for systemic use (ATC group J01), N=17 (N=7 in 2020). c. Methicillin-resistant Staphylococcus aureus (MRSA) rates, N=23. d. Carbapenem-resistant enterobacteria (CRE) rates, N=23