[Watch] COVID19 Antibiotic Overuse Sparks Drug Resistant Superbug Fear

What is it?

While the world is focused on fighting Covid-19, a less obvious but equally deadly pandemic is continuing to spread across the globe largely unchecked.

Antimicrobial resistance (AMR) is a threat that scientists and healthcare professionals have been grappling with for a long time, but the coronavirus pandemic threatens to exacerbate it in a number of ways.  

AMR is predicted to kill 10 million people by 2050 if it continues at its current rate with a report by the World Health Organization earlier this month underlining the dangers.

Resistance To Common Illness

It found high levels of resistance to antimicrobials used to treat common illnesses such as urinary tract infections (UTIs) or some forms of diarrhoea.

The rate of resistance to ciprofloxacin, an antimicrobial frequently used to treat UTIs, varied from 8.4 per cent to 92.9 per cent in 33 reporting countries.

Describing the threat of antimicrobial resistance as “one of the most urgent challenges of our time”, Dr Tedros Adhanom Ghebreyesus, director-general of the WHO, warned that the world is losing its ability to use critically important antimicrobial medicines.

Increased Antibiotic Use in COVID19

And he said the pandemic was making it worse. “The Covid-19 pandemic has led to an increased use of antibiotics, which ultimately will lead to higher bacterial resistance rates that will impact the burden of disease and deaths during the pandemic and beyond,” Dr Tedros said.

Covid-19 is not a bacterial infection, meaning that antibiotics will not work against it,

but there is concern that in the absence of testing and diagnostics,

doctors may be prescribing the drugs on the assumption the patient has a secondary bacterial infections.

“It was inevitable that physicians taking care of Covid-19 patients would have the urge to empirically use antibiotics just in case the patient has an infection, but also in mild cases of Covid,” Professor Hanan Balkhy, assistant director-general for antimicrobial resistance at the WHO told the Telegraph.

The Antibiotics Menance

A review of data from Covid-19 cases, mostly in Asia, found that 70 per cent of patients received antimicrobial treatment despite less than 10 per cent on average having bacterial or fungal infections.

The same study found frequent use of broad-spectrum antibiotics, which can further fuel resistance.

No Antibiotic Treatment for COVID19

The WHO has issued guidance to medics urging them not to provide antibiotic treatment to patients with mild Covid-19,

and has emphasised the need for proper assessment and diagnostic testing where available before antibiotic use in moderate and severe cases.

“We have to remember that when Covid appeared it did not eliminate the large number of viruses that also cause viral pneumonia,” said Prof Balkhy. “So in community settings where we do not have diagnostics, antibiotics seem to be the first empiric therapy used to try and manage a patient, and that has been exacerbated by the sheer number of patients that are having symptoms of respiratory illness.”

Dr Gemma Buckland-Merrett, science and research lead for drug resistant infections at Wellcome, says more data is needed on the amount of antibiotics being taken during the pandemic.

“There really is a lack of data but evidence currently suggests that cases of bacterial and fungal infections with Covid are low, but prescriptions of broad spectrum antimicrobial treatments have increased,” she told the Telegraph.

“If a patient has a confirmed secondary infection they need these treatments.

There is concern around treatments used for mild Covid cases, but we currently just don’t know what the levels of prescriptions are.”

Experts are keen to emphasise that, much like Covid-19, the problem transcends borders: resistance has been on the rise for years across the world, even if the drivers vary by country.

“When we talk about the misuse of antibiotics it can come in all shapes and forms,” said Prof Balkhy.

“In a high-income country it could be that intensive care units in hospitals have access to broad spectrum antibiotics and they use them empirically, whereas in mid-to-low income countries people who end up getting sick are given single pills. 

“By giving one or two doses you’re teasing the antibiotic, not killing it, and allowing it to develop mechanisms to resist the effect of the antibiotic if exposed again,” she added.

“It will acquire or redesign its genomic material to create ways to avoid the impact of that agent on itself.”

At the beginning of the pandemic in Scotland,

there was an increase in antibiotic prescribing for respiratory tract infections,

but since then there have been significant declines.

“We have quite a mature antibiotic stewardship programme in Scotland. A key message within our programme is to not prescribe antibiotics in mild respiratory infections and particularly if a viral infection is suspected,” said Dr Andrew Seaton, chair of the Scottish Antimicrobial Prescribing Group.

“With this in mind we’ve just completed a large survey of antibiotic prescribing in patients hospitalised with suspected Covid, and the suggestion is that fewer empirical antibiotics are being used in people with confirmed Covid infection in hospital than expected from published reports.”

Nations With Poor Health Systems at Risk

But in countries with less well developed health systems there is concern that opportunities to improve antibiotic stewardship have been squandered.

Diagnostic testing for Covid has been introduced in countries where it was not available before and AMR experts are concerned that these may be seen as simply short-term solutions.

“Because of Covid there are many lost opportunities over the last six months to strengthen and enhance the work needed to be done for the AMR agenda,” said Prof Balkhy.

“I also worry that countries are putting in solutions to Covid that could benefit AMR, but they’re not based on sustainable solutions. For example, enhancing diagnostic capacity through mobile labs is not a sustainable public health intervention. We need to build for the long haul.”

She added: “Once Covid no longer becomes a problem, all of the infrastructure put in place may disappear. Diagnostics and temporary hospitals are all going to disappear, so we aren’t really putting in place sustainable infrastructure. But antimicrobial resistance is already out there, and in my opinion it’s already a pandemic.”

Complicating the Post COVID Scenario

And a lack of access to both diagnostics and antibiotics is also complicating matters in developing countries, said Dr Seaton.

“We have a link with some hospitals in Ghana where we’ve been doing work there to collaborate on and promote antibiotic stewardship. It’s very challenging in resource-poor settings: you have the balance of limited access to medicines with few doctors, but lots of life-threatening infections. People must have access to treatment but also safety measures in place that prevent inappropriate use.

“The overlap between other respiratory tract infections and Covid and a lack of ability to test for either bacterial or viral pathogens adds to the diagnostic and treatment challenges,” he added.

Hospital Superbugs Scare

But the use of antibiotics to treat Covid patients and how that may increase resistance isn’t the only concern among experts: patients who spend a long time in hospital are at greater risk of picking up drug-resistant infections

“When patients are admitted to hospitals for long periods of time, the risk of getting secondary infections is increased,” said Dr Buckland-Merrett. 

“Evidence is currently suggesting that some Covid patients are getting secondary infections and some of these may be drug-resistant infections. Many patients are in hospital for a long time and if they are intubated the risk of acquiring a hospital-acquired infection is increased.”

Complex Issue

While the causes of antimicrobial resistance are multifaceted and complex, the overriding consensus from experts, especially as the threat is increased by Covid, is that solutions must be worldwide, sustainable, and done with urgency.

“This won’t happen without leadership at higher levels,” said Prof Balkhy.

“A little bit like climate change issues, it’s very complex.”