How Will COVID-19 Influence the Hidden Threat of Antibiotic Resistance?

[Authors: Clara Ballesté y Jordi Vila, coordinator and director, respectively, of the ISGlobal Antimicrobial Resistance Initiative]

The novel coronavirus pandemic has become the defining challenge of our time, affecting many (if not all) areas of our lives at both the individual and social levels. Much has been said about the impact of COVID-19 on the global economy and the psychological consequences of this most unusual situation. But what about the other public health challenges we face? In particular, what impact will COVID-19 have on antibiotic resistance?

Infections caused by treatment-resistant bacteria are currently one of the greatest threats to public health. As the World Health Organisation (WHO) first declared in 2016—and has reminded us ever since—tackling this issue will require the commitment of all nations. Unfortunately, although it is still too early to gauge its full impact, the new SARS-CoV-2 virus appears to be exacerbating the problem of antibiotic resistance. But what evidence points to this conclusion?

Unfortunately, although it is still too early to gauge its full impact, the new SARS-CoV-2 virus appears to be exacerbating the problem of antibiotic resistance

Firstly, in hospital settings, antibiotics have been widely used to eliminate possible bacterial superinfections in COVID-19 patients (a suspicion refuted by several recent studies). At the height of the pandemic, it makes sense that many health care workers—overworked, stressed-out and forced to make decisions on the fly—would err on the side of using antibiotics.

Moreover, some antibiotics have been used as combination or alternative therapies to treat patients with COVID-19. One example is teicoplanin, an antibiotic in the glycopeptide family that has been used to treat acute respiratory syndromes caused by other coronaviruses (SARS-CoV and MERS-CoV) as well as Ebola virus disease. However, we do not have enough scientific evidence of its efficacy to justify its use against COVID-19. Another example is azithromycin, an antibiotic in the macrolide family, which has been used in combination with other drugs for its immunomodulatory effect—that is, its ability to activate the body’s defences against the virus. However, to date there has been no conclusive research to support this use. On the contrary, recent studies have shown that azithromycin has no added value in the treatment of COVID-19.

In hospital settings, antibiotics have been widely used to eliminate possible bacterial superinfections in COVID-19 patients

Secondly, community-wide antibiotic prescription patterns suggest the existence of two contradictory trends that, in the best-case scenario, would cancel each other out. On the one hand, home confinement and restrictions on people’s movements may have contributed to a decrease in the number of doctor’s appointments, leading to fewer antibiotic prescriptions overall. On the other hand, telemedicine seems to have had the opposite effect: the inability to perform auscultation or collect samples to establish a real diagnosis may have led physicians to over-prescribe antibiotics out of an abundance of caution.

Finally, we mustn’t overlook environmental concerns. The growing concentration of biocides and disinfectants in sewage and wastewater treatment plants as a result of the widespread use of these substances—especially in hospitals—could have a significant environmental impact due to the selection of biocide-resistant bacteria and the emergence of cross-resistance to antibiotics. Further research is needed to confirm this hypothesis.

This combination of realities, situations and new attitudes may be driving an increase in antibiotic resistance. We must work to generate evidence that will help us put a stop to this phenomenon.

We mustn’t squander this opportunity. As a society, we can emerge from this crisis stronger than before, better educated in the field of infectious diseases and aware that antibiotic resistance is a silent yet dangerous threat lurking behind COVID-19

In the meantime, let’s remember the silver lining. On a social level, COVID-19 has increased the visibility of infectious diseases: what they are, who causes them, how they are treated and why vaccination is an essential tool for controlling infection. It has also changed people’s behaviour with regard to preventive measures such as wearing masks properly and washing their hands more frequently. Hand-washing, in particular, could have a positive impact on the fight against multidrug-resistant bacteria, as it may be one of the most effective ways to stop the spread of these microorganisms. At the policy level, hopefully this situation will lead to greater investment in infectious disease research, R&D for vaccines and treatments, and more resources dedicated to understanding and controlling the spread of infectious agents.

We mustn’t squander this opportunity. As a society, we can emerge from this crisis stronger than before, better educated in the field of infectious diseases and aware that antibiotic resistance is a silent yet dangerous threat lurking behind COVID-19.