An azithromycin tablet. Photo: testalizeme/Unsplash.
As health-care systems around the world fight to contain COVID-19, they may be inadvertently opening the door wider to another killer that is just as dangerous.
I’m talking about the spread of pathogens that are resistant to treatment, such as antibiotic-resistant bacteria. The death toll from COVID-19 is staggering, but so is that from antibiotic resistance: Nasty superbugs such as Clostridium difficile, or C. diff, currently kill some 700,000 people globally each year – that’s twice the number of Americans who died of COVID-19 last year. Left unchecked, antibiotic resistance may kill up to 10 million more people yearly and cumulatively cost patients and health systems up to $100 trillion by the year 2050.
Most patients presenting with symptoms related to COVID-19 are receiving antibiotics for additional infections, such as bacterial pneumonia. While this may save some lives, data show that antibiotics are being rampantly overused during the pandemic. What’s more, health-care workers who have to reuse gowns, gloves and other kinds of personal protective equipment (PPE) due to ongoing shortages risk spreading resistant bacteria between patients.
This trend is scary – but presents an opportunity to address these twin issues in tandem.
The increase in unnecessary use of antibiotics during COVID-19 is not a theoretical concern: A study published last August in Clinical Infectious Diseases found that of some 1,700 hospital patients in Michigan, more than half on average received early antibiotic treatment. Yet only 3.5% arrived at the hospital with bacterial infections. In May, a review of studies from the US and Asia reported that 72% of patients diagnosed with COVID-19 (1,450 of 2,010) were given antimicrobials. In the papers where researchers reported whether or not patients actually had other infections, only 8% (62 of 806) of people with COVID-19 were also diagnosed with bacterial or fungal infections.
Data show that antibiotics are being rampantly overused during the pandemic.
All this stands to be exacerbated by the concerning fact that, more than one year after COVID-19 emerged, health workers still don’t have enough PPE. A survey last summer from the American Nurses Association found that 68% of nurses had been required to reuse PPE due to a shortage of supplies. That could very well increase the risk that health practitioners will inadvertently spread resistant pathogens, especially if there are also errors in following the recommended PPE removal steps: A 2019 study found that about 30% of providers who cared for infected patients had traces of these deadly bugs on their PPE.
Even if providers have plenty of gear, the PPE itself can pose risks: Recently, researchers in England found that when providers wore long-sleeved gowns, per COVID-19 protocols, surfaces in patient areas were more likely to be contaminated with potentially deadly bacteria.
Not surprisingly, reports of problems from the field have been coming in. As early as May, after two months of PPE shortages, a hospital in New Jersey reported that 34 patients were infected with Acinetobacter baumannii, a pathogen resistant to the antibiotic carbapenem that usually caused two or fewer cases per month. Once COVID-19 caseloads dropped, lessening the impact of supply shortages, the bacterial infection rates returned to baseline. During a two-week period in August, half of COVID-19 patients in one Florida hospital tested positive for a drug-resistant strain of yeast (Candida auris); after providers made changes to PPE protocols and boosted cleaning practices, no further cases were reported.
As we grapple with containing the pandemic, health-care leaders worldwide have a chance to reboot how they approach antimicrobial resistance, as many of the tactics we use to fight one contagion could help beat back the other.
It goes without saying that we need to adequately equip our health workers, particularly when they are caring for COVID-19 patients. A review in ACS Nano published in August found that PPE production would need to increase by 40% to meet growing demand, and recommended that countries establish regional manufacturing centres. But this equipment – from gowns and gloves to masks and caps – will be protective and truly life-saving only if used properly. So providers must be trained on how to put on and take off PPE without inadvertently spreading pathogens. Organisations such as the US Centres for Disease Control and Prevention are providing such training, which some research suggests can help.
Programs that aim to enhance appropriate use of antibiotics – known as antibiotic stewardship – are a key component of the WHO’s Global Action Plan to fight antimicrobial resistance. But during the pandemic, health-care facilities’ plans to educate and monitor staff have often fallen by the wayside. So too have efforts to maintain surveillance and quality-control programs to beat back resistant pathogens. As a recent editorial in the Journal of Hospital Infection put it, antibiotic stewardship “has become a casualty of the COVID-19 pandemic.” This cannot continue.
Overburdened as they are, healthcare facilities have to recognise that efforts against both COVID-19 and antimicrobial resistance will work in tandem. Fighting one with surveillance, education and research will also help the other. Providers should integrate antimicrobial stewardship with all the measures they take to prevent and control contagious diseases such as COVID-19 and tuberculosis.
Of course, rolling out new treatments for antibiotic-resistant bugs would alleviate a lot of this pressure, but that is easier said than done. The US House and Senate introduced bipartisan legislation in late 2020 that would provide substantive government contracts to investigate new medicines. This is encouraging, as the field has suffered from a lack of funding and innovation.
Coordinating our responses to both scourges – COVID-19 and antibiotic resistance – in every facility and in our global health security efforts is the most efficient and effective way to go. The payoff will be millions of lives saved from both.
Mohan P. Joshi is a physician and senior principal technical advisor at the global health nonprofit Management Sciences for Health, where he is the technical lead for issues related to antimicrobial resistance and global health security.
This article originally appeared in Knowable Magazine, an independent journalistic endeavour from Annual Reviews.