Infection control
But clinicians battling Covid-19 on the frontline have another tool in their arsenal – one that came ten years too late to help doctors treating flu patients in 1918–19, and one that might have saved millions of lives: antibiotics.
An immediate challenge for healthcare professionals when Covid-19 took hold was stopping sick patients from contracting and dying from nosocomial bacterial and fungal infections. To that end – recognising the risks of co-pathogenesis of respiratory tract viruses like Covid – a high proportion of patients presenting early symptoms without pneumonia or moderate disease with pneumonia during the pandemic received antibiotics.
A WHO review of studies published in May last year put that figure at around three-quarters (72%) of hospitalised Covid-19 patients. However, the same review estimated that just 8% of those actually had confirmed bacterial or fungal infections. In ICUs, where the risk of hospital-acquired infection increases with the use of equipment like ventilators, wider antibiotic use is more justified. Yet according to a large-scale study conducted in ICU wards in 88 countries in 2017, and published in JAMA last year, while just over half (54%) of admissions in the 24 hour research period had suspected or confirmed bacterial infection, 70% of all patients were given antibiotics.
Of course, the problem with the overuse and misuse of antibiotic agents is that the bacteria they are designed to combat adapt and become resistant to treatment. Antimicrobial resistance (AMR) not only limits our ability to treat the most common infections, but also perpetuates the spread of multidrug-resistant organisms (MDROs), or ‘superbugs’. So, as hospitals worldwide filled to bursting with Covid-19 patients receiving prophylactic antibiotics, could efforts to limit the pandemic’s devastation have been inadvertently driving something even more dangerous? Gemma Buckland-Merrett is the science and research lead of the drug-resistant infections priority programme at the Wellcome Trust. She points out that there is as yet insufficient data to predict the extent of the long-term effects of Covid-related antibiotic use on antimicrobial resistance, but that evidence indicates there is likely to be some negative impact. “We have seen reports and anecdotal evidence of increased antibiotic use during the pandemic,” she says, “and the strong suggestion that at least some
The threat of multidrug-resistant organisms and AMR
By 2050, AMR could be responsible for ten million deaths each year across the world – some 1.8 million more than currently die from cancer annually. In the context of viral pandemics like Covid-19, infection with drug-resistant bacteria remains a significant factor in mortality. Bacteria had caused the deaths of almost half of people with Covid in a Wuhan hospital by the end of January 2020. During the 2009 H1N1 ‘swine flu’ pandemic, up to 55% of the 300,000 deaths globally were the result of secondary bacterial pneumonia. Source: Frontiers in Microbiology
of it has been inappropriate due to the fact that a lot of prescribing has been empirical.” In other words, patients have been given antimicrobial therapy anticipatorily, before a specific infecting pathogen is identified, or even shown to be present at all. Overuse of broad-spectrum antibiotics can certainly be a catalyst for drug resistance. “We haven’t seen any data that has looked systematically at a number of different countries and contexts, so we can’t say for certain if there has been an increase in inappropriate antibiotic use, or whether that has definitely impacted antimicrobial resistance or drug-resistant infections,” continues Buckland-Merrett. “But what we do know is that inappropriate use of antibiotics is a huge driver of antibiotic resistance.”
Clean hands
One benefit to emerge from the Covid-19 pandemic is greater awareness of hand hygiene, even among healthcare workers. Before the pandemic, effective, frequent handwashing was one of a suite of infection- prevention measures that hospitals had been emphasising to limit contamination and the spread of disease, as well as to tackle antimicrobial resistance. Accordingly, a study conducted in four hospitals in Los Angeles in the early stages of Covid (published in autumn 2020 in the American Journal of Infection Control) reported that “infection-prevention initiatives fostered among healthcare workers have increased awareness of effective handwashing, cleaning equipment after use and appropriate personal protective equipment use, which has subsequently decreased healthcare-acquired infections with multidrug-resistant organisms.” A 25% increase in the use of hand soap and alcohol-based hand sanitiser between the first and second quarters of 2020 was a major factor in lowering infection rates, the authors said. Elsewhere, however, some front-line hospitals have had to relax or suspend infection prevention programmes because of the magnitude of Covid- 19’s burden on services and staff. For example, screening and diagnostics have fallen by the wayside, antimicrobial stewardship teams have been redeployed, and isolation rooms and areas have been pushed to capacity with Covid patients, making it more difficult to keep cases of MDRO infection separate from the rest of the hospital population.
“I suspect that antibiotic-resistant infection surveillance activities, and the quality of data they produce, may be impacted because some surveillance systems have just been stopped,” Buckland-Merrett adds. “With a singular focus on one pathogen, together with overcrowding in hospitals and overloading of healthcare systems, we could potentially see an increase in multidrug-resistant infections as well.” Outside of hospital settings, a sharp rise in remote consultations is exacerbating empirical antimicrobial prescribing – another catalyst for AMR.
36 Practical Patient Care /
www.practical-patient-care.com
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