Dr. Rodney Rohde, a specialist in Virology, Microbiology, Molecular Biology, and clinical laboratory expert, explains how the COVID-19 pandemic can make antimicrobial resistance a bigger problem if health systems aren’t careful.
Like most of my public health; healthcare, medical laboratory, environmental services and other related professionals, I’ve spent the last seven months overwhelmed by the ongoing COVID-19 pandemic—and expect to continue to be overwhelmed. But when I get a chance to catch my breath, one worry that keeps coming back to my mind is the potential for this pandemic to amplify an already out of control, but resilient threat – the antimicrobial resistance epidemic. 
In its recent 2019 Antibiotic Resistance Threats in the United States, the Centers for Disease Control and Prevention (CDC) states that despite improvements in recent years, “the number of people facing antibiotic resistance in the United States is still too high. More than 2.8 million antibiotic-resistant infections occur in the United States each year, and more than 35,000 people die as a result. In addition, nearly 223,900 people in the United States required hospital care for C. difficile and at least 12,800 people died in 2017.” Likewise, a group of public health experts from the UN, international agencies and others released a report in April of 2019 stating that if no action is taken, “drug-resistant diseases could cause 10 million deaths each year by 2050 and damage to the economy as catastrophic as the 2008-2009 global financial crisis. By 2030, antimicrobial resistance could force up to 24 million people into extreme poverty.”
“drug-resistant diseases could cause 10 million deaths each year by 2050"
I have been personally involved in the war on antimicrobial resistance (AMR) for about two decades. It is personal to me for a number of reasons. Primarily, AMR has become an ongoing crusade for me because my father has been dealing with an ongoing methicillin resistant Staphylococcus aureus (MRSA) infection for many years. However, it is not just about my dad; it is about so many others that I have worked with regarding this terrible global crisis and pandemic. The ongoing need to educate the public about this threat is becoming life and death for so many. Despite the challenges of the current pandemic, antimicrobial resistance should still be front of mind for physicians and public health officials. This is especially true because without a good strategy, it’s possible the current pandemic could increase the threat.
How COVID-19 Could Make Antibiotic Resistance Worse
Imagine being in the current landscape for a physician or other healthcare provider that is responsible for tackling things like bacterial infections such as pneumonia, strep throat, or other similar respiratory ailments. Especially as schools are reopening and we move into the Fall, which is a prime time for flu viruses, allergies and other respiratory ailments. At a time when there are over 29 million COVID-19 infections globally, and almost 200,000 deaths in the United States, there will be times where overwhelmed doctors will prescribe antibiotics for the wrong infection.
Viruses are not killed by antibiotics, which target only bacteria. But a wrong prescription doesn’t just mean a patient gets the wrong treatment. When we take antibiotics incorrectly, either because of the wrong prescription or because we take antibiotics without a physician or pharmacist prescribing one, we create an environmental pressure cooker where bacteria can become superbugs, evolving because of the presence of antimicrobial medicines.
Other Risks the Pandemic Poses for Accelerating Antibiotic Resistance
In a recent Bulletin from the WHO, several experts discussed dangers that the ongoing COVID-19 pandemic will contribute to the threat of antibiotic resistance. They argue many people have been receiving antibiotics when presenting with mild cases of COVID-19 , but no pneumonia or even a moderate case with pneumonia. These are instances when antibiotics should not be prescribed. The article goes on to note that studies “published on hospitalized COVID-19 patients identified that while 72% (1450/2010) of patients received antibiotics, only 8% (62/806) demonstrated superimposed bacterial or fungal co-infections.”
There’s a secondary impact here because of the use of hydroxychloroquine, which is not yet recommended as a COVID-19 treatment outside of ongoing clinical trials. The World Health Organization reports that azithromycin (an antibiotic) is being widely used with the hydroxychloroquine treatment.
Another concern is that with higher COVID-19 hospital admissions, we are seeing increased numbers of healthcare associated infections (HAIs). A proportion of these infections will be multidrug resistant bacterial infections from microbes like Pseudomonas aeruginosa, Mycobacterium tuberculosis or any other number of these dangerous bacteria. Not only do these diseases threaten patients, but because of crowding of hospitals caused by the pandemic, there’s a greater risk of these diseases spreading to others. Likewise, the COVID-19 pandemic is leading to issues like fewer vaccinations or disruptions to ongoing treatments for HIV or other infections. These disruptions can and do lead to selection for resistance in bacteria.
We’re Not Rising Up to the Challenge of Antibiotic Resistance
Public health experts have been screaming about antibiotic resistance for decades. Yet, even in the face of our educational efforts for political leaders, policymakers, healthcare professionals, environmentalists and the public about the crisis, this slower but ever-present epidemic continues to be a low priority.
To make matters worse, public health and university research funding for the problem of antimicrobial resistance is dangerously underfunded compared to other infectious and non-infectious diseases. I would argue that this type of ongoing public health threat should be a line-item fund via governmental agencies. Public health matters all the time to everyone. Eternal, ongoing funding is critical to combat this threat. Unfortunately, too often we see the funding thrown at a current emergency (like COVID-19 ) in a reactive, knee-jerk response when we all know that a proactive, ongoing national strategy for any major public health threat makes more sense.
Antimicrobial resistance is dangerously underfunded compared to other infectious and non-infectious diseases.
The Importance of Antimicrobial Stewardship
Timothy Gauthier currently manages the Antimicrobial Stewardship Clinical Program for Baptist Health South Florida and has been an infectious diseases clinical pharmacist for the past decade in Miami, Florida. Antimicrobial stewardship is important for improving appropriate antibiotic use, which can secondarily reduce the chances for causing antibiotic resistance, but according to Gauthier, the COVID-19 pandemic has “pushed antimicrobial stewardship programs back onto their heels.”
It’s only natural that people’s attention is focused on the current crisis. However, Gauthier warns that if antimicrobial stewardship programs are more focused on COVID-19 , that means they are less focused on other matters. “This is something that is very concerning.” Says Dr. Gauthier. “While we need to focus efforts towards managing COVID-19 patients rationally, we also need to keep up our efforts to ensure optimal antimicrobial drug use.”
How Medical Systems Can Do Their Part
The authors of the above-mentioned WHO Bulletin propose antimicrobial stewardship activities should be integrated into the COVID-19 pandemic response across the broader health system through five measures:
- Increase clinical competence among health workers treating COVID-19 patients through targeted training in order to prevent misdiagnosis.
- Ensure the continuity of essential health services and regular supply of quality assured and affordable antimicrobials including antiretroviral and tuberculosis drugs and vaccines.
- Reduce the turnaround time of COVID-19 testing by improving testing methods and expanding testing facilities, especially for presumed patients, to reduce the urge to initiate antibiotics.
- Exercise maximum caution in the use of biocides for environmental and personal disinfection and prioritize biocidal agents without or with a low selection pressure for antibiotic resistance.
- Address gaps in research to ensure that antimicrobial stewardship activities become an integral part of the pandemic response and beyond.
It is also important to ensure physicians are not relying on telehealth to accurately diagnose respiratory infections such as flu, strep and others. Running a test in the office or clinic ensures you are not prescribing antibiotics unnecessarily.
If these principles are kept front and center, then medical systems can treat COVID-19 patients rapidly and efficiently, without increasing the risks of antimicrobial resistant infections.
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