By Linya Thng
The highly infectious coronavirus illness 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is a health concern throughout the world. COVID-19 emerged as a global pandemic responsible for over 2.9 million deaths – the highest mortality rate since the era of the 1918 Influenza pandemic (Hassan et al., 2020). Research focusing on bacterial respiratory coinfection in SARS-CoV-2 infection cases is still in its infancy. The COVID-19 pandemic exacerbated pre-existing pressures in the global healthcare setting towards treating antimicrobial resistance. Challenges include limited resources for antimicrobial stewardship, extensive preemptive antibiotic use in COVID-19 patients and deteriorating economic conditions that are potentially fueling resistance levels. As such, the problem of antimicrobial resistance (AMR) remains a significant threat. This article focuses on shifts in attitudes towards antimicrobial usage and the burden of AMR in treating COVID-19 patients.
Antimicrobial resistance, a rising global issue resulting from the persistent abuse of antibiotics since 2015 (WHO, 2015), has already been designated as a global public health priority for the year 2020 (WHO, 2020). In general, antimicrobial therapy is prescribed to patients with COVID-19 for two reasons. The first is the resemblance between COVID-19 and bacterial pneumonia symptoms. Patients hospitalized with COVID-19 were typically given empirical antibacterial therapies, oftentimes in the absence of microbiological verification of diagnosis (Langford et al., 2021). Such practices can potentially impact future drug resistance levels of other pathogens. The second reason why antimicrobial therapy may be administered is that patients with COVID-19 may acquire secondary co-infections. Despite this only occurring in <4% of COVID-19 hospitalized patients, hospital-acquired pneumonia was documented in a large proportion of hospitalized patients and is noted to be caused by S. aureus, P. aeruginosa and Klebsiella pneumoniae (Garcia-Vidal et al., 2021). There is now a substantial push to collect more data on such cases. As such, where diagnostic laboratory infrastructure is available, standardized definitions and diagnostic criteria should be employed for more in-depth analyses of microbiological resistance and antimicrobial usage data (Lansbury et al., 2020).
An increasing concern in treating COVID-19 patients is the rise of AMR associated with antimicrobial usage. To address the variations in COVID-19, governments implemented short-term interventions (such as increased sanitary precautions, travel limitations, and fewer elective hospital procedures) focused on temporarily reducing AMR pathogen selection and transmission. The general purpose of empirical treatment is to address a wide spectrum of suspected pathogens – thus, AMR influences the recommended antimicrobials prescribed to COVID-19 patients by clinicians (Gutíerrez-Gutierrez et al., 2017). Local stewardship guidance therefore faces conflicting priorities. In terms of prioritization, prescribing a broad-spectrum antibacterial can stabilise a vulnerable individual; yet, there is a constant need to reduce unnecessary antimicrobial use, especially in circumstances where a narrower-spectrum antimicrobial would suffice. Broadly speaking, inadequate therapy in either direction leads to a higher mortality rate. The rise of antimicrobial resistance necessitates a delicate balance between the use of empirical treatment and the prudent use of antibiotics within defined timeframes, unless otherwise warranted.
What are the impacts of AMR on COVID-19? Three main factors influence the evolution of AMR in a population: emergence, transmission, and infection burden at the population level. Selective pressures on microbial populations in humans, animals, and the environment can all contribute to the emergence of AMR. The transfer of these newly emerging antimicrobial-resistant organisms (AROs) between humans, animals, and environments may be enabled or prevented as a result of environmental conditions and behaviors. The quantity and variety of infections, as well as the availability, effectiveness, and safety of alternate therapies, will determine the severity of ARO-related illnesses (Langford et al., 2021). To combat COVID-19, the government has implemented a variety of measures, including domestic and foreign travel restrictions, school, workplace, and non-essential service closures, enforcement of masks, and physical distancing measures. Although not a reliable option, the antibiotic regimen is temporarily deemed most appropriate for the treatment of secondary bacterial infections. The combination of improved data collection and a greater understanding of microbiological mechanisms will improve COVID-19 treatment techniques, raise the precision of treatments available, and allow governments and health organizations to implement effective policy.
Despite the focus on the global COVID-19 pandemic, AMR is still a problem. In reality, the AMR landscape lies at the root of many issues encountered throughout this pandemic. Whilst health systems struggle to deal with this new disease, other secondary conditions to COVID-19 must remain a public health priority. Consideration of the impact of COVID-19 on AMR from a global perspective is essential, as the treatment obstacles and their impact on AMR will vary by country and location. The combination of health informatics and a greater understanding of microbiological mechanisms will improve COVID-19 treatment techniques, raise the precision of medicine available, and give governments and health organizations capacity for effective intervention and policy implementation. The pandemic’s supposedly unpredictable and incalculable nature becomes more transparent and unambiguous through these efforts, allowing for improved public health outcomes.
References:
Hassan, S. A., Sheikh, F. N., Jamal, S., Ezeh, J. K. and Akhtar, A. (2020), ‘Coronavirus (covid-19): A review of clinical features, diagnosis, and treatment’, Cureus (Palo Alto, CA); Cureus 12(3), e7355. page 3
WHO (2015) Global action plan on antimicrobial resistance. [Online]. Available from: https://www.who.int/publications-detail-redirect/9789241509763.
WHO (2020) Antimicrobial resistance. [Online]. Available from: https://www.who.int/westernpacific/health-topics/antimicrobial-resistance
Garcia-Vidal, C., Sanjuan, G., Moreno-Garc ́ıa, E., Puerta-Alcalde, P., Garcia-Pouton, N., Chumbita, M., Fernandez-Pittol, M., Pitart, C., Inciarte, A. and Bodro, M. (2021), ‘Incidence of co-infections and superinfections in hospitalized patients with covid-19: a retrospective cohort study’, Clinical Microbiology and Infection 27(1), 83–88. pages 10
Langford, B. J., So, M., Raybardhan, S., Leung, V., Soucy, J.-P. R., Westwood, D., Daneman, N. and MacFadden, D. R. (2021), ‘Antibiotic prescribing in patients with covid-19: rapid review and meta-analysis’, Clinical Microbiology and Infection . page 11
Lansbury L, Lim B, Baskaran V, Lim WS (2020) ‘Co-infections in people with COVID-19: a systematic review and meta-analysis’, Journal of Infection 81:266-275
Guti ́errez-Guti ́errez, B., Salamanca, E., de Cueto, M., Hsueh, P.-R., Viale, P., Jos ́e Ramo ́n Pan ̃o-Pardo, Venditti, M., Tumbarello, M., Daikos, G. and Canto ́n, R. (2017), ‘Effect of appropriate combination therapy on mortality of patients with bloodstream infections due to carbapenemase-producing enterobacteriaceae (increment): a retrospective cohort study’, The Lancet Infectious Diseases 17(7), 726– 734. Page 11
Imperial Bioscience Review 