Project Summary/Abstract The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in over 26 million infections and overwhelmed healthcare systems throughout the U.S. The novel nature of COVID-19 has generated unprecedented diagnostic and therapeutic dilemmas. One area of emerging concern is the collateral impact of the pandemic on increased antibiotic prescribing and an associated acceleration of bacterial resistance. For instance, early reports indicate that a high percentage of patients hospitalized with COVID-19 receive antibiotics despite few having confirmed bacterial co-infections. In addition to the public health implications, overuse of antibiotics is also a threat to patient safety due to the risk of serious adverse drug events and Clostridioides difficile colitis. In January 2021, the Society for Healthcare Epidemiology of America issued a white paper outlining research priorities related to COVID-19 that highlighted an urgent need to “identify the impact of changes in health care utilization and delivery on antibiotic prescribing” and “develop and implement optimal Antimicrobial Stewardship Program (ASP) strategies to improve antimicrobial use and patient outcomes while adapting to changing healthcare delivery during COVID-19”. This project is specifically designed to address this call to action as we aim to comprehensively characterize the impact of the COVID-19 pandemic on antibiotic prescribing and bacterial resistance trends in acute care hospitals and identify strategies that effectively promote resilient antibiotic stewardship. The assembled team is uniquely qualified to conduct this project given our expertise in evaluating antibiotic prescribing patterns, access to data from ~350 U.S. hospitals and extensive experience using systems engineering methods to analyze stewardship interventions. For the quantitative analyses, we will first characterize overall and condition specific antibiotic prescribing trends before and after COVID-19 using an interrupted time series analysis. Next, we will identify patient and hospital level factors that increased the risk of non-indicated antibiotic prescribing during the COVID-19 pandemic, with the goal of identifying potential intervention targets. Finally, we will complete a systems engineering guided qualitative analysis, focused on hospitals that least and most effectively mitigated the impact of COVID-19 on antibiotic prescribing, to identify systems-level contextual factors and strategies. These results will be used in a multidisciplinary co-design process to develop an antibiotic stewardship implementation toolkit that enhances resiliency during operational upheaval and is transferable between organizations. Given the dynamic nature of the pandemic (e.g. variant strains), it is imperative to classify the previous, ongoing and future adverse impacts on antibiotic prescribing to guide development of tailored stewardship strategies for widespread dissemination. This work represents a vital contribution to AHRQ’s ongoing efforts to combat both COVID-19 and the longstanding pandemic of antimicrobial-resistant infections.

Project Narrative Significant concern exists about the COVID-19 pandemic causing increased antibiotic prescribing in hospitals and accelerating the public health threat of bacterial resistance. In this project, we will measure the impact of COVID-19 on overall and condition specific antibiotic prescribing and bacterial resistance patterns using data from a diverse, nationally representative group of over 350 U.S. hospitals. We will then conduct interviews with healthcare professionals at hospitals with varying alterations in antibiotic prescribing during the pandemic to identify effective strategies for inclusion in a resilient antibiotic stewardship implementation toolkit.