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How Has COVID-19 Affected Antimicrobial Resistance?

As the COVID-19 pandemic blanketed the United States in 2020, reports indicate it contributed to more than 310,000 deaths. By comparison, the less visible threat of antimicrobial resistance might seem less significant. After all, “only” about 35,000 Americans die each year from this phenomenon.1 But while the promise of vaccines provide encouraging hope for relief from the COVID-19 pandemic, there is no similar light at the end of the tunnel for antimicrobial resistance.

Consider the consequences of failing to address antimicrobial resistance. Because of the limited treatments available, infections due to antibiotic-resistant organisms already cause more than 700,000 deaths annually worldwide.  But by 2050, without coordinated action to preserve the efficacy of current antibiotics and to develop new therapeutic options, an estimated 10 million people worldwide could die each year from drug resistance.2

“It’s quite difficult to wrap our heads around that type of number,” says Brian Lee, MD, a Clinical Science Director at Roche Molecular Diagnostics and an infectious disease specialist. “But keep in mind that antibiotics really are the foundation of much of what we do in modern medicine.”

To understand what Dr. Lee means, let’s take a look at sepsis, which arises in at least 1.7 million U.S. adults every year.3 Without effective antibiotics, the condition will not only be harder to treat — it will also become much more prevalent. That’s because common infections that we currently take for granted as easily treatable, like those affecting the skin and urinary tract, could become untreatable in the absence of effective antibiotics, Dr. Lee says. Similarly, prevention and cure of infections among the most vulnerable, including patients undergoing invasive surgeries, with chronic conditions, or with cancer, will be more difficult. And, he says, all of these infections could then evolve into sepsis, which will have an escalating mortality rate as antibiotic options diminish.

Despite implementing an action plan to combat antimicrobial resistance in 2015, the U.S. faces a steep challenge. COVID-19 may have amplified the threat in some ways and alleviated it in others, Dr. Lee says. Although no one knows for sure what the net impact will ultimately be, he recently outlined early observations that strongly suggest we must not lose sight of antimicrobial resistance amid the COVID-19 pandemic.4

How COVID-19 Could Worsen Antimicrobial Resistance

The first challenge could be geopolitical. Dr. Lee worries that failure to collaborate with international partners to curb the spread of the coronavirus and emergence as one of the hardest-hit nations could hurt the U.S.’s leadership and credibility in the global fight against antimicrobial resistance. The decision to withdraw from the World Health Organization could further limit the U.S.’s influence in global health policy, he says.

As healthcare system and public health resources have tightened, funding for programs that are vital for controlling antimicrobial resistance have suffered a blow — including antimicrobial stewardship programs, infection prevention programs, and immunization efforts, Dr. Lee says. He pointed to an analysis predicting that COVID-19 lockdowns could interrupt tuberculosis prevention and treatment campaigns and result in 1.8 million additional deaths over the next 5 years. Tuberculosis already accounts for 30% of global antimicrobial resistance deaths.5

The intense focus on COVID-19 in U.S. hospitals could also worsen antimicrobial resistance, Dr. Lee says. Due to staffing shortages, clinicians have been forced into new and unfamiliar roles. “You might have, for example, an ophthalmologist, who is now working on the inpatient wards and prescribing antibiotics for pneumonia, which they may not have done in many years,” Dr. Lee adds. “That leads to variability in care, and that often means less appropriate care.”

Clinicians who typically oversee hospital antimicrobial stewardship programs might have also assumed new roles to combat COVID-19. That could hamper efforts to promote the judicious use of antibiotics in healthcare settings, Dr. Lee says. Such efforts may have become even more vital in the context of the pandemic, given data indicating that there has been an overprescribing of antibiotics for COVID-19. Although fewer than 4% of COVID-19 patients arrive at the hospital with a bacterial co-infection, more than 70% of patients received an antibiotic.6

What’s more, Dr. Lee adds, the focus on use of personal protective equipment and isolation for patients with COVID-19 could divert attention away from the prevention of transmission of multidrug-resistant organisms. If that’s the case, hospitals could see outbreaks of these difficult-to-treat bacteria.

How COVID-19 Could Improve Antimicrobial Resistance

It’s not all bad news. Before the pandemic, few people outside healthcare regularly thought of infectious diseases and their public health impact. Now that these are consistently front-page news, Dr. Lee hopes that in the long run, this will lead to a reinvestment in the public health system and in initiatives to combat antimicrobial resistance.

“Only time will tell,” he adds.

A similar situation is unfolding in within U.S. hospitals. Infectious disease physicians and antimicrobial stewardship experts have had increased visibility due to the pandemic, often interacting with healthcare leadership and building influence. This arrangement could pave the way for future prioritization of antimicrobial stewardship efforts within healthcare systems, Dr. Lee says.

In addition, hospitals have long struggled to foster adherence to infection prevention measures, but with the pandemic, these practices have become entrenched in a way not previously seen. Everyone wears masks, clinicians are taking overall PPE use seriously, and hand hygiene is no longer an afterthought. This shift not only reduces the spread of COVID-19 but also prevents the transmission of other infections, including antibiotic-resistant organisms, Dr. Lee notes.

And while patients with COVID-19 might receive too many unnecessary antibiotics, many hospitals are admitting fewer patients for non-COVID conditions. “Because these other patients are not being hospitalized, we’re actually using fewer antibiotics overall,” Dr. Lee adds. “So that actually could help improve antimicrobial resistance.”

Finally, the lightning-fast development of COVID-19 vaccines provides proof that government incentives are effective in getting the job done, Dr. Lee says. If upfront funding worked for the pandemic, why couldn’t the same approach be used to stimulate antibiotic development and novel innovations in the fight against antimicrobial resistance?

Antimicrobial Resistance Will Likely Persist Long After COVID-19

All in all, when considering whether the COVID-19 pandemic will help or hinder efforts to address antimicrobial resistance, it’s a mixed bag. “In the end, the net long-term impact is really far from clear,” Dr. Lee says. “But I think what we need to keep in mind is that during this unprecedented time, we really must not lose sight of the longer-term threat of antimicrobial resistance.”

Because whether antimicrobial resistance has a devastating impact on future generations across the globe depends on how we act now.


References

1. “Biggest Threats and Data: 2019 AR Threats Report.” U.S. Centers for Disease Control and Prevention, 2019, https://www.cdc.gov/drugresistance/biggest-threats.html. Accessed Dec. 17, 2020.

2. “New report calls for urgent action to avert antimicrobial resistance crisis.” World Health Organization, April 2019, https://www.who.int/news/item/29-04-2019-new-report-calls-for-urgent-action-to-avert-antimicrobial-resistance-crisis. Accessed Dec. 17, 2020.

3. “Sepsis: Clinical Information.” U.S. Centers for Disease Control and Prevention, Dec. 2020, https://www.cdc.gov/sepsis/clinicaltools/index.html. Accessed Dec. 17, 2020.

4. “Antimicrobial Resistance in the Time of COVID-19.” Sepsis Alliance Institute, Nov. 2020, https://www.sepsisinstitute.org/content/sponsor-innovation-webinar-antimicrobial-resistance-time-covid-19. Accessed Dec. 16, 2020.

5. “1.8M people could die from tuberculosis in 2020: WHO.” Devex, Oct. 2020, https://www.devex.com/news/1-8m-people-could-die-from-tuberculosis-in-2020-who-98312. Accessed Dec. 18, 2020.

6. “Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis.” Clinical Microbiology and Infection, July 2020, https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30423-7/fulltext. Accessed Dec. 18, 2020.