Shri Vinoba Bhave Civil Hospital
The emergence of COVID-19 pandemic has presented an enormous challenge to the current health system and workers. However, there is a significant concern that the pandemic will cause an increased number of deaths due to a rise in antimicrobial resistance (AMR) termed as an “invisible pandemic” by the World Health Organization (WHO). Broad-spectrum antimicrobials are used popularly among hospitals, both as empiric and direct therapy to a minority of patients with severe COVID-19 who might develop superinfections.
Few studies have directly assessed COVID-19 with associated superinfections and AMR. Since World Antimicrobial Awareness Week 2020 was being celebrated worldwide from 18th to 25th November 2020 with the slogan “Antimicrobials: handle with care,” it is time to discuss the effect of COVID-19 on AMR.
COVID-19 and Superinfection/Coinfection and AMR Interactions
Hospitalization of COVID-19 cases in ICU, especially those undergoing mechanical ventilation, can reach up to 14 days resulting in an increased risk of hospital-acquired infection (HAI). Coinfection during COVID-19 diagnosis is uncommon, as few patients developed superinfections during hospitalization. These ﬁndings are different compared to 1918 pandemics when bacterial superinfections were common causes of mortality and morbidity. Different studies have been conducted among COVID-19 hospitalized patients, reporting rates of secondary infection ranging between 0 % to 15 %. The reasons for discrepant findings between studies are still unclear, but the major reason is that most of the studies have been retrospective. There is no single protocol for collecting sputum, blood, or other samples for microbiologic cultures.
Most pathogenic organisms reported in COVID-19 patients are multidrug-resistant (MDR) nosocomial organisms such as Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. In a study conducted by the All India Institute of Medical Sciences, New Delhi, India, MDR was found in 60% isolates with overall resistance up to 84% and a mortality rate of 33%.
Hospitalized COVID-19 patients are at greater risk of superinfections, and thus physicians often employ empiric antimicrobial therapy with broad-spectrum agents, leading to increased risk of antimicrobial resistance. According to the National Institute for Health and Care Excellence (NICE) guidance to treat severe pneumonia, patients will receive the broad-spectrum antibiotics doxycycline or amoxicillin as an alternative irrespective of the cause. Empiric antimicrobial usage is widespread because it was challenging to exclude bacterial or fungal superinfections in many severely ill COVID-19 patients based on signs and symptoms, radiographic abnormalities, and laboratory results. So far, published data indicate that the primary use of antimicrobials for patients admitted with COVID-19 ranges between 56% to 95%.
Indirect Effect of COVID-19 on AMR
As explained above, COVID-19 has a direct effect on an increase in AMR in the health care setting. However, the indirect effect of COVID-19 on the transmission of AMR to the environment should also be of concern. The increased levels of antimicrobials released in wastewater from hospitals will affect the levels of antimicrobials in the environment. This will affect the level of resistance in both wildlife and feed animals. The fight against the COVID-19 pandemic has also shifted the resources available for different infectious diseases, including AMR management, towards the pandemic response. Various health workforce, including Infectious diseases physicians, are now in the front line for the fight against COVID-19 affecting AMR-related work in hospitals. Shifting of the microbiologist to COVID-19 related testing further aggravates the above factor. Another aspect worth considering is the increased use of hand sanitizers and antimicrobial soaps for protection against COVID-19. Although its benefit cannot be argued, it is worth looking into some of them, which may contain additional chemicals that may fuel bacterial resistance. It is known that bacteria use efflux pumps to develop resistance against disinfectants and the same efflux pump contributes to AMR.
Learning from Covid-19
COVID-19 pandemic and AMR are interrelated health emergencies that provide a unique opportunity for mutual learning. Thus, current strategies used to fight against COVID-19, such as rapid response, increased collaboration, government support, public response and development of new vaccines, treatment, and testing methods, are also required to combat AMR. These responses were already being used for AMR, but at a much slower pace and smaller scale. Lessons learned from COVID-19 can also be replicated at a faster scale against the invisible pandemic of AMR. It is also necessary to use the experience acquired during COVID-19 to reconsider the administration of empiric antibiotic therapy to all admitted patients. Before initiating antimicrobial therapy, suitable specimen collection and utilization of all available diagnostics should be made available to exclude other causes of infection. Antimicrobial therapy should be reserved for cases where differentiation between bacterial and viral infections is not possible and must be reviewed once microbial test results are available.
Behavioral changes such as mask-wearing and social distancing to prevent COVID-19 will probably decrease the spread of other infections and, thus, the use of antimicrobials. Understanding how COVID-19 affects AMR trends in the long term will help us plan the next step for counteracting AMR. Researchers need to collect data to measure the impact of current COVID-19 policies on AMR. At present, both COVID-19 and AMR have multiple potential interactions. How will it affect the future is still uncertain?