Antimicrobial Resistance and COVID-19
High variation in the mortality rates due to COVID-19 across countries has been observed. Although the causes for such a wide variation are multiple and difficult to disentangle, variation in the prevalence of Antimicrobial Resistance (AMR) across countries is part of the list of suspects. Hence, it is unavoidable to ask: How do AMR and COVID-19 interrelate?
Opinion piece by Gloria Cordoba
On 5th of May WHO launched the new global campaign on hand hygiene - a key component of the strategies to control the spread of AMR and COVID-19. In the following article, Assistant Professor Gloria Cordoba reflects on the interrelation of AMR and COVID-19.
A chicken-and-egg situation
Trying to explain the mechanism of interrelation is far from being an easy task, as it calls to mind the “chicken-and-egg" situation.
Firstly, how could AMR worsen COVID-19?
Effective antibiotics are crucial for the management of bacterial infections. However, antibiotics do not work on viral infections, of which COVID-19 is one. Even so, bacterial co-infection is an important cause of morbidity and mortality in viral infections such as COVID-19. During the current pandemic, small studies (see notes) have shown that 50% of patients of confirmed COVID-19 cases have a bacterial co-infection. How many deaths in these cases can be attributed to ineffective antibiotics (i.e., AMR)? This issue is still under study.
Secondly, how could COVID-19 worsen or improve AMR?
The long fight to curb the development and spread of AMR is facing a critical moment. The way we, as a global society, respond to the COVID-19 challenges now may have an effect, positive or negative, on our ability to fight AMR.
COVID-19 might be causing a rise in the inappropriate use of antibiotics, mainly broad-spectrum antibiotics. Excessive and inappropriate use of broad-spectrum antibiotics is one of the main causes for the development of AMR. An increasing number of patients with undefined upper and lower respiratory tract symptoms, coupled with high fever, might be putting doctors under pressure to prescribe antibiotics.
Furthermore, in many countries, patients with mild symptoms have been encouraged to consult via teleconsultation (i.e., video or call). These consultations have decreased the possibility of performing relevant clinical examinations and diagnostic tests. It leads to an impaired diagnostic accuracy and an increased risk of inappropriate antibiotic prescribing.
Besides, the acute changes in the workflow in settings where antimicrobial stewardship programs (ASP) were already in place might be impeding the judicious follow-up of these programs. It might result in an unsystematic/uncontrolled process for checking the appropriateness of the antibiotic prescription.
A momentum not to be missed
The COVID-19 pandemic is giving us a unique opportunity to reinforce key principles for the containment of AMR. COVID-19 has amplified the message of the importance of the principles established by WHO many years ago to curb the development of AMR.
Firstly, the importance of key components of infection control and prevention (IPC), such as hand hygiene, has been finally understood. Now is time to move forward, creating innovative solutions to assess compliance and quality of hand hygiene. It is also the time to encourage governments to continue the momentum started to prioritise strengthening the capacity building of the core components of the IPC program set forth in 2016 by WHO.
Secondly, the importance of optimising the use of antibiotics is gaining momentum as societies have become aware of the devastating consequences of not having treatment options for treating an infectious disease. In record time WHO has launched the "Solidarity clinical trial" and other groups are following the same path. With the participation of many countries, these initiatives aim to obtain, also in record time, high-quality evidence on the best treatment option, weighing benefits and harms. This coordinated effort and the process cannot become a one-time COVID-19 action. It must continue, as there is still a worrisome lack of knowledge about the optimal use of antibiotics for bacterial infections and management of bacterial co-infection in viral cases such COVID-19. Optimising the use of antibiotics is crucial to contain the development and spread of AMR.
Thirdly, COVID-19 has amplified the importance of developing accurate and easy to use diagnostic tests for the surveillance and management of infectious diseases. The unprecedented synergy between the private sector, academic institutions, international organisations, and governments to develop, manufacture, and distribute diagnostic tests cannot stop when tests for COVID-19 are not needed any longer. The development of user-friendly and accurate diagnostic tests for guiding the decision of prescribing antibiotics and guiding the selection of antibiotics is still in its infancy. Hence, this unprecedented synergy has to continue if we are to control the development of AMR.
Finally, COVID-19 has increased the importance of two crucial aspects in the fight against AMR. Today, it is impossible to deny the importance of cross-national and coordinated efforts to curb the spread of infectious diseases (i.e., bacterial and viral). No country can tackle a threat alone, and a weak response or inaction in one country has consequences beyond its borders. Furthermore, the need to take action based on evidence gained through a One-Health approach is needed now more than ever. COVID-19 has made it impossible to deny that the common environment in which animals and humans interact leads to common health outcomes. Solutions to control the spread of infectious diseases require, therefore, the concerted work of multiple disciplines and agencies beyond the health care sector.
The COVID-19 disease will eventually disappear, but AMR will not. The appropriate handling of future pandemics will require that all actions aimed at decreasing the spread and development of AMR are in place to avert the moral and social cost of preventable deaths.