Antibiotic Resistance: An Underrecognized Crisis From the COVID-19 Pandemic

Yash B. Shah


March 11, 2022

The COVID-19 pandemic has undoubtedly exposed weak points in our healthcare system. To nobody's surprise, a major concern is antibiotic resistance, which was already a global challenge prior to the pandemic, according to the World Health Organization (WHO).

This issue has become more relevant for all healthcare providers throughout the pandemic because a lack of attention to antibiotic stewardship, a primary contributor to emerging antibiotic resistance, could undo decades of work against the alarming growth of antibiotic-resistant microorganisms.

Antibiotics are routinely used to treat bacterial infections. But when microorganisms are exposed to harmful conditions, they face selective pressure that leads to adaptations over time to escape this survival limitation. Hence, these organisms evolve to become resistant to certain drugs.

Development of antibiotic resistance allows bacteria to infect many more people because we may lack the proper tools or approach to control these infections. Resistance can even spread between different types or subtypes of bacteria, resulting in exponential spread. The more a resistant organism is allowed to spread, the more danger it poses for the outside community and the higher the risk for eventual escape from a greater proportion of the antibiotics that are at our disposal.

Inappropriate overuse of antibiotics can create unwarranted evolutionary pressure on microorganisms, accelerating the development of resistance. Without ongoing research and development of novel therapies, we will lose the ability to kill highly resistant microorganisms, which results in the rapid spread of life-threatening infections.

As a message to all healthcare providers, the WHO concluded that the current clinical pipeline is insufficient to keep up with emerging resistance. Knowing the implications of such a finding, we need to continue to promote effective messaging emphasizing the importance of proper antibiotic prescribing that reinforces the principles of antibiotic stewardship.

During the pandemic, staffing shortages, increased patient volume, and shortages of medical supplies placed a lower priority on infection control and antibiotic control programs. Similarly, monitoring the spread of antibiotic-resistant bacteria may not have been as critical as the task of creating bed space to care for the rapid influx of COVID-19 patients.

Simply put, COVID-19 management diverted resources and focus away from antibiotic use oversight to pandemic response planning for one simple reason: conserving bed capacity and nurses to care for COVID-19 patients in the hospital.

Unfortunately, this shift in focus also occurred on a systemic level. The Centers for Disease Control and Prevention has a network of nationwide laboratories that conduct testing in hospitals, communities, and water or soil environments to track antibiotic-resistance patterns. This network is designed to rapidly detect emerging resistance and inform local responses that can prevent spread or further evolution.

Testing for antibiotic resistance at these facilities dropped 23% from 2019 to 2020 as public health workers shifted focus toward COVID-19. This reduced prescription oversight, and analysis of infection patterns may have contributed to the development and spread of resistant organisms. A 2019 pre-pandemic UN report found that the annual death toll of antibiotic resistant infections is expected to reach 10 million by 2050, but this troubling estimate will probably rise owing to the pandemic.

Given this backdrop, data indicate that antibiotic use has spiked over the past several years. This issue originated from a variety of factors. Primarily, COVID-19 was believed to be difficult to distinguish from other respiratory infections, such as community-acquired pneumonia.

Early in the pandemic, when testing and diagnostic tools for COVID-19 were not yet available, antibiotics were often administered prior to diagnosis. Because our COVID testing infrastructure remains lacking, empiric antibiotics continue to be administered for suspected COVID-19 patients as a precaution prior to test results being returned.

Hence, there is no role for antibiotics in the initial management of COVID-19 patients, according to Robert Glatter, MD, assistant professor of emergency medicine at Lenox Hill Hospital and editor-at-large for Medscape Emergency Medicine. Although empiric antibiotic treatment for suspected bacterial infections is often clinically beneficial, such as in patients with sepsis and severe sepsis, patients with COVID-19 do not fit this category.

Data certainly indicate that patients hospitalized with COVID-19 are more susceptible to nosocomial (hospital-originating) infections because of compromised immunity or the need for invasive procedures such as intubation. After such an infection, antibiotics are likely necessary. However, only 10% of hospitalized patients with COVID-19 actually acquire a secondary infection. Between 70% and 97% of patients hospitalized with COVID-19 received antibiotic therapy, which is startling because these drugs certainly cannot treat the virus itself.

Infections acquired in a hospital are much more likely to be drug-resistant, highlighting the troubling nature of this trend.

Glatter states that both clinical approaches and therapeutics for treating COVID-19 have undergone a significant progression since the early days of the pandemic. Clinicians must be vigilant to practice antibiotic stewardship to not only reduce antibiotic resistance but also reduce the rise of drug-resistant pathogens.

This ultimately translates to improved outcomes, including reduced length of stay, which is a win-win for patients and providers alike.

Patient education gaps still remain. Although it may seem like common knowledge in the healthcare space that viruses cannot be treated with antibiotics, many patients still demand these prescriptions for COVID-19.

Moreover, increased usage of telehealth may have further precipitated antibiotic overprescription. Although a pre-pandemic study demonstrates much higher rates of antibiotic prescription during telehealth appointments, we also realize that the pandemic saw a massive increase in virtual healthcare usage.

One example of increased resistance that has already been seen is with azithromycin. Early in the pandemic, lacking treatment options, many providers experimented with this commonly used antibiotic for COVID-19 treatment. It has since been confirmed that this antibiotic has no benefit in COVID-19, but data indicating increased azithromycin resistance have already been noted since 2020.

In summary, the pandemic produced two important issues: excessive and misinformed use of antibiotics in patients with viral infections and the increased need for justified, evidence-based use in patients with possible secondary infections who are at risk for COVID-19.

Overprescription of antibiotics not only hurts our society and its resources in the long-term but it also creates short-term detriments for individual patients. For instance, antibiotics often have troubling adverse effects including adverse drug reactions that can reduce quality of life during the course of the prescription.

We will eventually emerge from the COVID-19 pandemic, or at least learn to live with endemic virus and achieve a sense of post-pandemic normalcy. However, we must work hard to ensure that the pandemic does not pave the way for other infectious agents, creating even greater challenges for our society in the future.

Robert Glatter, MD, assistant professor of emergency medicine at Lenox Hill Hospital and editor-at-large for Medscape Emergency Medicine, was an expert contributor to this piece.

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About Yash B. Shah
Yash Shah is a first-year medical student at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania. He earned a bachelor of science in premedicine from Penn State University. Prior to attending medical school, Yash worked on clinical and translational research in hematology/oncology at the Children's Hospital of Philadelphia. Yash has long-standing interests in advancing medical education, improving healthcare policy and economics, and working with cancer patients. In his free time, he enjoys playing tennis, rooting for the Eagles, reading, and traveling.


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