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. 2024 Oct 31;4(1):e192.
doi: 10.1017/ash.2024.417. eCollection 2024.

A quasi-experimental analysis comparing antimicrobial usage on COVID-19 and non-COVID-19 wards

Daniel Doyle  1 , Bruce Dalton  2 , Zuying Zhang  3 , Deana Sabuda  2 , Irina Rajakumar  2 , Elissa Rennert-May  1   3   4   5   6 , Jenine Leal  7   3   4   6 , John M Conly  1   7   4   5   6   8
Affiliations

A quasi-experimental analysis comparing antimicrobial usage on COVID-19 and non-COVID-19 wards

Daniel Doyle et al. Antimicrob Steward Healthc Epidemiol. .

Abstract

Objective: To describe antimicrobial usage (AMU) trends before and during the coronavirus disease 2019 (COVID-19) pandemic, between COVID-19 and non-COVID-19 wards, and if there was any association with a COVID-19 order set.

Design: Quasi-experimental retrospective interrupted time series analysis of AMU rates with a contemporaneous comparison of COVID-19 versus non-COVID-19 control wards. Analysis using incidence rate ratios (IRR) was conducted using a Poisson regression generalized linear model.

Setting: Five COVID-19 and 4 comparable non-COVID-19 wards and 6 intensive care units (ICUs) at 4 hospitals during pandemic waves 1-4.

Participants: All inpatients receiving systemic antimicrobials.

Intervention: The COVID-19 checkbox antimicrobial order set was implemented in March 2020, to be used only if considered clinically indicated with modification in August 2021.

Main outcomes and measures: The primary outcome was a change in AMU rates (defined daily dose per 100 patient days per month) comparing pre- versus peri-pandemic periods and COVID-19 versus control non-COVID-19 wards. Secondary outcomes included antifungal usage rate in ICUs and assessing AMUs following implementation and modification of a COVID-19 order set.

Results: Significantly greater rates of AMU (IRR[95%CI]) were observed on COVID-19 wards versus non-COVID-19 wards during waves 1-4 for all systemic antimicrobials (1.76[1.71-1.81], 1.10[1.07-1.13], 1.48[1.43-1.53], and 1.06[1.03-1.09]); for azithromycin (11.76[9.80-14.23], 10.96[9.49-12.74], 12.41[10.73-14.45], and 4.88[4.31-5.55]); and for ceftriaxone (2.39[2.16-2.65], 3.64[3.29-4.03], 2.94[2.67-3.23], and 1.62[1.49-1.76]).

Conclusions: We observed significantly increased AMU rates of all systemic agents during the first 4 waves of the pandemic and on COVID-19 wards compared with control wards for azithromycin and ceftriaxone. These agents saw a twofold reduction following order-set removal, suggesting that the clinical decision-support tool order set, as utilized, had influenced prescribing behavior.

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Conflict of interest statement

Dr. John Conly has held grants from the Canadian Institutes for Health Research on acute and primary care preparedness for COVID-19 in Alberta, Canada, and was the primary local Investigator for a Staphylococcus aureus vaccine study funded by Pfizer for which all funding was provided only to the University of Calgary. He is a co-investigator on a WHO-funded study using integrated human factors and ethnography approaches to identify and scale innovative IPC guidance implementation supports in primary care with a focus on low-resource settings and using drone aerial systems to deliver medical supplies and personal protective equipment to remote First Nations communities during the COVID-19 pandemic. He also holds grants from the Snyder Institute and a Catalyst Grant from the VPR Office at the University of Calgary for studies on the transmission of SARS-CoV-2 in K18-mice and received funding from BioMérieux Canada for accommodations and travel expenses to attend a meeting on AMR in 2022 and accommodations and travel expenses from the 2023 International Conference on Prevention & Infection Control meeting to attend an IPC Think Tank meeting outside the scope of the submitted work. He is a member and Chair of the WHO Infection Prevention and Control Research and Development Expert Group for COVID-19 and a member of the WHO Health Emergencies Programme ad hoc COVID-19 IPC Guidance Development Group, both of which provide multidisciplinary advice to the WHO and for which no funding is received and from which no funding recommendations are made for any WHO contracts or grants. He is also a member of the Cochrane Acute Respiratory Infections Working Group. No other authors have conflicts of interest to disclose.

Figures

Figure 1.
Figure 1.
All systemic antimicrobial usage (DDD per 100 patient days) from 2018 to 2021 representing the pre-pandemic period compared with each of the first severe acute respiratory coronavirus virus 2 waves. P values are reported beneath each graph for the designated comparison. Note: DDD, defined daily dose; ICU, intensive care unit.
Figure 2.
Figure 2.
Azithromycin antimicrobial usage (DDD per 100 patient days) from 2018 to 2021 representing the pre-pandemic period compared with each of the first 4 severe acute respiratory coronavirus virus 2 waves. P values are reported beneath each graph for the designated comparison. Note: DDD, defined daily dose; ICU, intensive care unit.
Figure 3.
Figure 3.
Ceftriaxone AMU (DDD per 100 patient days) from 2018 to 2021 representing the pre-pandemic period compared with each of the first 4 severe acute respiratory coronavirus virus 2 waves. P values are reported beneath each graph for the designated comparison. Note: AMU, antimicrobial usage; DDD, defined daily dose; ICU, intensive care unit.
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