key: cord-329737-l8u4s73w authors: Liew, Yixin; Lee, Winnie Hui Ling; Tan, Lunyi; Kwa, Andrea Lay Hoon; Thien, Siew Yee; Cherng, Benjamin Pei Zhi; Chung, Shimin Jasmine title: Antimicrobial stewardship program, a vital resource for hospitals during the global outbreak of Coronavirus Disease 2019 (COVID-19) date: 2020-08-27 journal: Int J Antimicrob Agents DOI: 10.1016/j.ijantimicag.2020.106145 sha: doc_id: 329737 cord_uid: l8u4s73w Healthcare resources are being diverted for the containment and control of COVID-19. During this outbreak, we caution that antibiotic misuse may be increased, especially for respiratory tract infections. With stewardship interventions, duration of antibiotic therapy and length of stay of hospitalized patients can be significantly reduced. Antibiotic stewardship programs should continually engage and educate prescribers to mitigate antibiotic misuse during the COVID-19 pandemic. In early Dec 2019, reports of Coronavirus Disease 2019 (COVID-19) patients first emerged in Wuhan, China 1 . On 23th Jan 2020, Singapore's first reported case of COVID-19 in Singapore was identified at the Singapore General Hospital 2 . Since then, the Ministry of Health, Singapore, quickly raised "Disease Outbreak Response System Condition" (DORSCON) alert to orange (the second highest level of alert) on 7th Feb 2020, and implemented various measures nationwide, including border control, quarantine of contacts of COVID-19 cases or those who have travelled to affected areas, temperature screening as well as restricting the number of visitors to the hospital. As of 26 th July 2020, Singapore has had 50, 369 confirmed cases. 1 In light of increasing COVID-19 cases locally and internationally, 2 our hospital faced competing manpower needs arising from health crisis management, leading to uncertainty over manpower allocation of non-direct patient care personnel e.g. antibiotic stewardship practitioners. Here, we aim to describe the impact of COVID-19 on antibiotic use and the role of Antibiotic Stewardship Program (ASP) in Singapore General Hospital (SGH), an 1800-bed, tertiary-care hospital. Our multidisciplinary ASP comprises of 9 trained infectious diseases pharmacists, as well as 3 infectious disease (ID) physicians. The pharmacy team performs daily audits electronically, of selected broad-spectrum antibiotic prescriptions (carbapenems, piperacillin-tazobactam, ciprofloxacin and levofloxacin) for appropriateness, in terms of indication, route, duration and choice and intervenes where appropriate; the audited prescriptions of more complex cases are reviewed daily with the attending ID physician who is rostered for the day. 3 When Singapore raised the DORSCON alert to orange, our institution mandated cancellation of elective and non-urgent procedures / surgeries, to ring-fence more beds for dedicated respiratory and pneumonia wards in preparation for larger scale outbreak. Negative pressure rooms in our hospital are solely used for COVID-19 suspects and cases. Operationally, face-to-face meetings were discouraged within the institution and the workforce was generally divided into small teams (e.g. 5-10 members per team), as part of the hospital's business contingency plan. Accordingly, our ASP team was divided into two pharmacy teams so that ASP would still be operationally functional with one team if the other team had to be quarantined. In place of face-to-face meetings, daily ASP meetings with the ID physician were conducted via teleconferencing. The first COVID-19 case was reported in Singapore on the 23 rd Jan 2020, and as the number of cases increased, a stay-at-home order and cordon sanitaire termed "circuit breaker" was implemented as a preventative measure on the 7 th Apr 2020. 2 This epidemic has placed enormous strain on healthcare providers and healthcare systems worldwide. Locally, our country has placed a high emphasis on identifying and isolating COVID-19 patients in our bid to contain the spread of the virus. In the early weeks of our containment strategy, patients with signs and symptoms suggestive of viral illness were actively screened and isolated until results return negative for COVID-19. Consequently, we perceived that there were more admissions of patients with acute respiratory illness, which would otherwise have been treated in the community in prior to the COVID-19 pandemic. These patients were usually started empirically on antibiotics used for the treatment of community-onset pneumonia coinciding with the increased utilization of these agents. Furthermore, our initial hypothesis that the use of broad-spectrum antibiotics should drop together with the admission numbers was debunked. Instead, prescription numbers for these agents were observed to increase as they target serious, nosocomial infections which are often associated with urgent conditions (e.g. cancer for which treatment cannot be delayed). Hence, in a tertiary healthcare institution like ours, the impact of COVID-19 as well as the continued care for hospitalized patient with complex medical issues, culminated in the higher proportion of patients on antibiotics compared to pre-COVID period. It would be prudent to maintain the ASP even in viral epidemics / pandemics with existing manpower support. 4 At the start of the pandemic, we received support from hospital management to maintain the ASP as an essential service, a commitment towards our continued fight against antimicrobial resistance. We also learnt the importance for ASPs to be operationally adaptable to different scenarios. Organizational restructuring and migration to telecommuting platforms for our ASP activities was crucial for maintaining our clinical service while observing distancing measures, thus ensuring patient and staff safety in this pandemic. We also realized that in addition to focusing our efforts on nosocomial treatments, this is an opportunity for our team to execute a syndromic approach towards guiding antibiotic prescribing for respiratory tract infections. To do so, we must employ digital platforms and continue to develop robust surveillance systems that are able to detect subtle changes in prescribing and resistance trends. What is also important in outbreak situations like these is on-going engagement and education of prescribers to mitigate antibiotic misuse that tends to occur with viral epidemics / pandemics, undoing years of progress in antibiotic stewardship. Given that we are engaged in this COVID-19 battle for a long haul, the role of ASP is vital to ensuring the quality of our antibiotic use is upheld because the problem of antibiotic resistance remains in the long term. 5 The Singhealth Centralised Institutional Review Board approved this retrospective review of our service. Informed consent was not obtained from individual patients as the operations of the ASP constituted routine clinical practice and only anonymized data were analyzed. COVID-19) Situation Report -41. World Health Organization Updates on COVID-19 (Coronavirus Disease 2019) Local Situation. Ministry of Health Singapore Discontinuation of antibiotic therapy within 24 hours of treatment initiation for patients with no clinical evidence of bacterial infection: a 5-year safety and outcome study from Singapore General Hospital Antimicrobial Stewardship Program COVID-19: don't neglect antimicrobial stewardship principles! COVID-19 and the potential long-term impact on antimicrobial resistance We would like to acknowledge all ASP pharmacists for their contribution to the study.