How the coronavirus crisis can fuel antimicrobial resistance – analysis
Developing countries are reeling from the burden of drug-resistant infections. Low availability and utilization of diagnostics and compromised infection control in communities and hospitals result in overuse of antimicrobials. It contributes to the development of highly resistant pathogens that are difficult to destroy. It is well known that diarrhea and upper respiratory tract infections are generally caused by viruses, but they account for more than 60% of antimicrobial prescriptions. With a growing focus on antimicrobial resistance globally, India has taken small but important steps to introduce antimicrobial administration to streamline its prescriptions in hospitals.
The coronavirus disease pandemic (Covid-19) threatens to undermine these efforts, all the more so in resource-poor settings with fragile health systems. Like most other viral respiratory tract infections, Covid-19 is self-limiting and causes a mild form of the disease in most patients. In the absence of specific antiviral treatment, patients are prescribed antibiotics in hospitals around the world.
Research published in China, Italy, and the United Kingdom shows that the majority of people hospitalized with Covid-19 infection received antibiotics despite little evidence of associated bacterial infections. Although there are no published reports from India, anecdotal evidence suggests that bacterial coinfections are rare in patients with suspected severe Covid-19 who require hospitalization.
With labs rapidly shifting their focus to Covid-19 and antimicrobial susceptibility testing / prioritization cultures, the evidence for secondary bacterial or fungal infections in Covid-19 patients is limited. Not enough cultures are sent to confirm the presence of secondary bacterial or fungal infections of patients with Covid-19. There is a significant risk to laboratory personnel collecting samples and the technicians who process them due to a shortage of personal protective equipment (PPE) and biosafety challenges in laboratories.
Such concerns have led many hospitals to not perform routine microbiological examinations on patients with Covid-19, undermining the diagnosis and treatment of secondary infections. Since it is difficult to distinguish between bacterial or fungal infections and existing viral pneumonia based on clinical symptoms and radiological findings, the microbiological examination will be valuable in diagnosing secondary infections to guide antimicrobial prescription. It is imperative to strengthen the investigation of secondary infection and / or coinfection in patients with Covid-19 in all health centers without compromising the safety of laboratory personnel.
Until there is evidence that Sars-CoV-2, the virus that causes Covid-19, is associated with bacterial or fungal co-infections, antibiotics should not be prescribed and patients should be treated symptomatically. Even when antibiotics are prescribed, the narrowest spectrum agent should be prioritized to attack potential pathogens. India has very high resistance rates to some of the broad-spectrum antimicrobials. It is advisable that such antibiotics be reserved for situations where differentiation between bacterial and viral etiology is not possible based on clinical symptoms. If symptoms are severe, antibiotics should be prescribed based on local epidemiology and antibiograms (susceptibility of a specific microorganism to a battery of antimicrobial drugs). If Sars-CoV-2 infection is confirmed, the prescription of antibiotics should be reviewed and discontinued, unless there is clear evidence of bacterial coinfection.
In the absence of a vaccine and doubts about Sars-CoV-2 immunity, the coronavirus pandemic may last longer than expected. Better infection control practices are expected to decrease the incidence of hospital-acquired infections. However, there will always be a possibility that a certain percentage of patients require antimicrobials to treat secondary infections. The line of new antimicrobials is drying up and no new antimicrobials are seen immediately. We will need antimicrobials long after the coronavirus crisis ends.
Therefore, it is important to define indications for the use of antibiotics in patients with Covid-19 and to follow the principles of antimicrobial administration. If indiscriminate prescription continues, it will jeopardize the gains the country has made in introducing antimicrobial administration to the hospital. Stepping carefully and using the available antimicrobials wisely will prevent us from jeopardizing antifungal and antibacterial treatments after Covid-19 has ended.
Kamini Walia is the Program Officer, Antimicrobial Resistance, Indian Council for Medical Research. The opinions expressed are personal.
The opinions expressed are personal.