The COVID-19 pandemic has been raging on for almost one year. In addition to the impact on health systems, with almost 66 million confirmed cases and over 1.5 million deaths as of early December 2020, the pandemic has caused widespread social and economic disruption.
In spite of the tragedies and devastation, we’ve also seen that astounding progress can be made when adequate resources and attention are devoted to a specific problem; in less than one year, at least two competing vaccine candidates have passed through clinical trials and are ready for mass production and distribution with a third close behind.
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The challenges posed by the ongoing pandemic should be taken as warnings for another growing threat: antimicrobial resistance – the ability of a microorganism to survive the effects of an antimicrobial agent. Interestingly, these problems are not independent of one another. Viral infections, such as that caused by SARS-CoV-2, the virus that causes COVID-19, could increase the risk of bacterial coinfection, as was seen during the H1N1 influenza pandemic in 2009.
Thus, in March the World Health Organization recommended empirical antibiotic therapy in cases of severe acute respiratory infection when COVID-19 is suspected. However, a recent review of literature surrounding coinfection in patients with coronavirus infection reported that 72% of patients received antimicrobial therapy although only 8% were documented as experiencing bacterial or fungal coinfections.
Though coinfections seem to be uncommon during COVID-19, a recent study conducted in Catalonia during Spain’s first wave found that antibiotic usage increased significantly through March and April 2020 compared to 2019. In particular, empirical amoxicillin/clavulanate trended upwards during the first wave of hospitalizations in March 2020, followed by an increase in broad-spectrum antibiotic prescriptions, including antibiotics on the World Health Organization’s List of Essential Medicines such as meropenem and piperacillin/tazobactam in April 2020.
Thus, despite limited evidence of coinfection during coronavirus infection, the pandemic may be increasing consumption of broad-spectrum antibiotics. Interestingly, this trend varies by region; a hospital outside of a COVID-19 epicenter reported decreased antibiotic consumption for March-June 2020.
Nevertheless, this worrying trend calls for evidence-based antibiotic stewardship, such as the suggestions put forth by the Dutch Working Party on Antibiotic Policy:
1. Restrictive use of antibacterial drugs in patients with proven or high likelihood of COVID-19, especially for patients with mild to moderate illness
2. COVID-19 patients with radiological/inflammatory marker findings consistent with bacterial co-infection, or severely ill or immunocompromised patients may be considered for antibacterial therapy
3. Obtain sputum and blood samples for culture and urine for antigen testing prior to starting empirical antibacterial therapy
4. In cases of suspected coinfection, recommend against empirical antibiotic treatment covering atypical pathogens
5. Empirical antibacterial treatment regimens for suspected bacterial coinfection should depend on severity of infection and follow local guidelines
6. Stop antibiotic treatment if culture and antigen tests taken before the start of empirical antibiotic treatment show no bacterial pathogens after 48 hours of incubation
7. Antibiotic treatment duration of 5 days in COVID-19 patients with suspected bacterial coinfection who show improvements of signs and symptoms
It should be noted that the majority of these recommendations are based on Good Practice standards and weak evidence.
Outside of COVID-19 infections, the pandemic may actually be reducing antimicrobial exposure due to behavioral changes:
· Higher hygiene standards
· Greater infection control measures
· Reduced travel and social interaction
· General avoidance of care centres and the emergence of telehealth
Without long-term data, the ultimate impact of the COVID-19 pandemic on AMR remains unclear. However, and perhaps more importantly, since we know that increased antibiotic exposure correlates with emergence of resistance, care should be taken to adhere to antimicrobial stewardship best practices.
The pandemic offers a critical and unique moment in terms of how it has drawn the public’s attention towards infectious diseases and vaccine research. As such, policy-makers, public health professionals, and other antimicrobial stewards should seize upon this distinct opportunity to continue building awareness of the looming threat of AMR.