Conclusion

In our survey, formulary restrictions for COVID-19 therapeutics were commonly reported (n = 94, 96%) and approval by ID clinicians was commonly necessary (n = 77, 81%). The role of other specialties was significantly lower, with pulmonary/critical care as a distant second (n = 43, 44%). Though restrictions were present for most therapies, they were more commonly used for immunomodulators. Hospitals where ID physicians did not order or approve restricted medications had more unrestricted use of these medications. In smaller hospitals, this may reflect lack of access to ID physicians. Formulary restrictions may be a crucial tool for pandemic response in that they ensure access to medications to those who need them when availability is limited. A wider gap between remdesivir use and guideline concordance in hospitals without formulary restrictions has been reported. ^{Reference Mena Lora, Burgos, Borgetti, Chaisson and Bleasdale6} Our survey highlights the value of ID clinicians to healthcare systems in allocating resources and promoting evidence-based practices during the COVID-19 pandemic.

Several obstacles made it challenging to bring novel COVID-19 therapies to the bedside. Rapidly evolving literature and conflicting guidelines often led to differences in the management of COVID-19. ^1,2 ASP can help standardize therapy, inform clinicians of changing guidelines and novel therapies, and align treatments with evidence-based guidelines. ^{Reference Pierce and Stevens3,Reference Barlam, Al Mohajer and Al-Tawfiq4} Supply constraints and cost also make stewardship imperative. During the initial months of the pandemic, there was high demand for remdesivir and limited supply. ⁷ Similarly, tocilizumab was in short supply at various points of the pandemic due to very high demand. ⁸ High cost and demand at a time when healthcare systems are under financial pressure by other aspects of the pandemic, such as decreased revenue and rising staffing costs, make stewardship a crucial part of pandemic response. ^{Reference Berlin, Lapointe, Murphy and Wexler9} Remdesivir, for example, costs approximately $520 per vial, totaling over $2,000 per course. ^{Reference Wang, Levi, Ellis and Hill10} Similarly, tocilizumab and baricitinib cost approximately $3,625 and $2,326, respectively, when used for COVID-19. ^{Reference Wang, Levi, Ellis and Hill10} Thus, stewardship is vital to ensure the evidence-based use of pharmaceuticals that may be both expensive and in limited supply. The high cost and supply constraints of immunomodulators may be contributing factors to why these agents were more commonly restricted.

ID physicians have been at the frontlines of pandemic preparedness and response, often taking on multiple roles. These roles include providing clinical care, conducting clinical research, providing advice on infection prevention and control, influencing public policy, educating the public, and creating treatment protocols and management plans for COVID-19 patients. Our survey highlights the contribution of ID physicians in the stewardship of expensive and at times limited supply of medications. At a time with rampant disinformation and significant therapeutic controversies, ASP and ID physicians have been instrumental in ensuring that these medications are used appropriately, based on clinical guidelines and in accordance with the principles of stewardship. Indeed, the pandemic has further highlighted the value of ID physicians and of collaborative multidisciplinary stewardship teams.

Our study has several limitations. Our convenience sample was small, and ID physicians and pharmacists may have been more likely to participate due to our use of ID society listservs. Our survey did not capture specific hospital guidelines or timing of the formulary restrictions. Nonetheless, our study offers important knowledge on stewardship strategies and ID physician roles ring the COVID-19 pandemic.

Emerging and re-emerging infections will continue to pose challenges for clinicians. Lessons learned during the COVID-19 pandemic may help us prepare for future challenges. In this survey, we found that ASP and drug formulary restrictions were a common strategy during the COVID-19 pandemic. The important role played by ASP and ID physicians in the stewardship of expensive medications during the COVID-19 pandemic highlights the value of ID in yet another critical area of pandemic response.