From Pandemic to Resistance: The Unintended Consequences of COVID-19 on Antimicrobial Practices

Introduction

The Covid-19 pandemic has resulted in significant alterations to healthcare practices, including increased infection prevention measures, changes in diagnostic procedures, and the reallocation of healthcare resources. Subsequently, this pandemic placed an enormous strain on healthcare systems worldwide, resulting in the redirection of resources and attention away from antimicrobial stewardship programs. This article explores the repercussions of COVID-19 on antimicrobial resistance and highlights the importance of addressing this emerging threat.

Discussion 

Antimicrobial resistance is the broader term for resistance in different types of microorganisms (eg, bacteria, viruses, parasites, or fungi). It encompasses resistance to antibacterial, antiviral, antiparasitic, and antifungal drugs. Resistant microorganisms emerge either by mutations or the procurement of mobile genetic elements that carry the resistance gene. Therefore this can occur irrespective of the presence of antimicrobials. However, it is the exposure to these drugs that gives rise to the growth and spread of resistant pathogens (Prestinaci, 2015). Inappropriate prescribing (whether caused by obsolete guidelines or pharmaceutical pressures), over-the-counter antibiotic availability, and self-medication reflect a general lack of awareness of the global threat that antibiotic resistance poses to our society. Medical procedures such as surgery could become exceedingly difficult, or even impossible, due to antimicrobial resistance (Ibid). Common infections may become untreatable, which could lead to death. 

Director-General Margaret Chan stated in the foreword to the Global Action Plan that "Antimicrobial Resistance is a crisis that must be managed with the utmost urgency. As the world enters the ambitious new era of sustainable development, we cannot allow hard-won gains for health to be eroded by the failure of our mainstay medicines" (2015).  However, clinical trials worldwide implemented the use of antimicrobial agents for the treatment of Covid-19 infections. A plethora of drugs have been used in prophylaxis and treatment of covid infections including several antivirals (lopinavir/ritonavir combination, remdesivir, and favipiravir); two antimalarials (chloroquine and hydroxychloroquine); ACE2 inhibitor (losartan); immunosuppressive agents (tocilizumab, leronlimab and corticosteroids); TMPRSS2 inhibitor (camostat mesylate); anti-parasitic drugs (ivermectin and nitazoxanide); a gold-containing drug, auranofin, an immunomodulator used in sepsis and leprosy (Sepsivac, mycobacterium w (heat-killed) injections); allogeneic Placental expanded (PLX) cells; and convalescent plasma (Breining, 2019; Evan, 2019; Caly, 2020; Diederich, 2020; Smith, 2020; Barkama, 2020; Patel, 2021; Mirjalili, 2022; Massai, 2022). In addition, during the COVID-19 pandemic, soaps and antimicrobial disinfectants have been increasingly used by hospital staff. If these products are based on chlorhexidine digluconate or quaternary ammonium compounds, this can also lead to antibiotic resistance. 

The uncertainty surrounding the early stages of the pandemic and the lack of specific antiviral treatments contributed to clinicians prescribing antibiotics empirically to manage suspected bacterial co-infections. In addition, the clinical presentation of Covid-19 can mimic bacterial infections, leading to diagnostic uncertainties. Delayed diagnosis or misdiagnosis of bacterial co-infections may result in suboptimal antibiotic management, potentially fueling antimicrobial resistance (Ha et al, 2017). Therefore the frequent use of antibiotics for the antiviral therapy of covid patients further aggravated the antibiotic resistance crisis. Antiviral drugs like remdesivir, favipiravir, and others have been used frequently to manage COVID-19 patients (Smith, 2020; Eroglu, 2021). 

A study by Yale Schools of Medicine and Public Health has conveyed a remdesivir-resistance variant of SARS-CoV-2 in an immunocompromised patient who was being treated with remdesivir (Gandhi et al, 2022). Patients with Covid-19 have weakened and compromised immune systems, making them reliant on antiviral therapy to control the virus, and subsequently making them more prone to developing resistance to the treatment they receive. The focus on managing Covid-19 cases may have led to reduced monitoring of antimicrobial prescribing practices, hindering efforts to prevent inappropriate antibiotic use. 

Antibiotic prescriptions for inpatients and outpatients led to a setback in the combat against antibacterial resistance (Ha et al, 2017; Hodoșan et al, 2023). The prevalence of antibiotic-resistant pathogens among patients with laboratory-confirmed Covid-19 and bacterial infections emphasizes the urgency of antimicrobial stewardship. Research findings show that approximately 72% of COVID-19 patients admitted to hospitals received antimicrobial treatment, despite only 8% of them having bacterial or fungal co-infections (Rawson et al, 2020). Moreover, various antibiotics such as azithromycin have been suggested for COVID-19 treatment. The mass public concern, in addition to the inappropriate use of antibiotics, directly affects antibiotic access without a prescription, especially in developing countries with weak antibiotic control systems. For instance, it was reported that nearly 69% of COVID-19 patients had used antibiotics like ceftriaxone and azithromycin before hospital admission (Zavala-Flores et al, 2020).

Conclusion

The indiscriminate use of antibiotics in the management of COVID-19 patients, combined with diagnostic uncertainties and empirical prescribing, has contributed to the rise of antimicrobial-resistant pathogens. This emerging crisis demands urgent action and strengthened antimicrobial stewardship programs. The prevalence of antibiotic-resistant pathogens among COVID-19 patients underscores the need for prudent antibiotic use and careful monitoring of prescribing practices. Efforts should be directed towards promoting awareness about the global threat of antimicrobial resistance and the importance of appropriate antibiotic use. Collaborative efforts between healthcare providers, policymakers, researchers, and the pharmaceutical industry are crucial in addressing this issue and safeguarding the threatened utility of antibiotics for future generations.

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