Increased Antibiotic Resistance — Another Hidden Consequence of COVID-19?

Late last year I wrote about The Good and Bad News of Antibiotic Resistance…in a Post-Antibiotic Era. The Centers for Disease Control and Prevention (CDC) had just published the second “Antibiotic Resistance Threats in the United States” report, calling for continued aggressive actions to prevent infections, improve antibiotic stewardship, and stop the spread of resistance when it does develop.

And then COVID-19 happened.

On the surface there doesn’t seem to be much of a connection between COVID-19 and antibiotic resistance. After all, COVID-19 is caused by the virus SARS-CoV-2 and antibiotics are not used to treat viral infections, right? Well, unfortunately, that may not be the case. Initial data from Wuhan identified that antibiotics were used in approximately 53% of patients with non-severe disease and more than 90% of patients admitted to the hospital or the ICU. Since then, there have been multiple reports and scientific papers highlighting the high use of antibiotics to treat COVID-19 patients. Given that antibiotic use is a main contributor to antibiotic resistance, the treatment of COVID-19 infections may have an impact on the growing antibiotic resistance problem.

Why are COVID-19 patients receiving antibiotics?

COVID-19 patients are receiving antibiotics to treat secondary bacterial lung infections and hospital acquired infections. In some cases, they are also being used as a last resort effort. Empiric therapy for suspected bacterial infection in COVID-19 patients, which is recommended by the WHO, may be complicating the issue as non-specific antibiotics are prescribed prior to identifying the specific bacteria causing the infection. Although this approach may be necessary at this time, it is counter to the antibiotic stewardship best practice of conducting microbial analysis before prescribing antibiotics and could be contributing to an increase in “antimicrobial pressure” on pathogens to become resistant.

What types of antibiotics are being prescribed?

There have been reports of the use of azithromycin, amoxicillin, tetracycline, doxycycline and teicoplanin (which is a last-resort antibiotic used to treat methicillin-resistant Staphylococcus aureus (MRSA) infections). Azithromycin has been shown to cause antibiotic resistance in some bacteria, such as Streptococcus pneumoniae. Drug-resistant Streptococcus pneumoniae (S. pneumoniae) is a leading cause of bacterial pneumonia and meningitis in the U.S., and is estimated to cause 900,000 infections and 3,600 deaths in the U.S. each year. It is listed as a serious antibiotic-resistant threat in the CDC 2019 report.

What is the potential impact?

With currently (as of May 27, 2020), almost 1.5 million cases and almost 100,000 deaths from COVID-19 in the U.S. alone, the potential for increased antibiotic resistance is high. While all antibiotic use has the potential to increase antibiotic resistance, so much in such a short amount of time has potentially sped up the process. Without having new antibiotics to replace the ones that no longer work, there could be additional risk of not surviving an infection for both COVID-19 and non-COVID-19 patients now and in the future. 

The potential short-term impact was recently summarized in this way by Dr. Julia Gerberding, former CDC director and infectious disease expert: “The challenge of antibiotic resistance could become an enormous force of additional sickness and death across our health system as the toll of coronavirus pneumonia stretches critical care units beyond their capacity.”

In the longer term, an increase in antibiotic resistance threatens the progress that we have made in recent years and undermines current efforts. The CDC’s 2019 report estimated that almost 3 million infections from antibiotic-resistant bacteria still occur in the United States each year, resulting in almost 36,000 deaths. Antibiotic resistance also has a significant economic impact such as extended hospital stays, additional follow-up visits to healthcare providers, and the use of treatments that may be more costly and potentially more toxic. Ultimately, this adds to the burden of high healthcare costs we are already facing.

So what can we do about it?

Time will tell the true impact that COVID-19 will have on antibiotic resistance. However, there are actions we can take today to help offset any additional negative impact we may see. For clinical staff, antibiotic stewardship principles should remain at the forefront of our efforts. For pharmaceutical companies and government, we need to do everything in our power to develop new antibiotics for the future. And finally, for everyone, perhaps the most important and impactful thing we can do is to help prevent infections in the first place. These infection prevention fundamentals, which I believe should also be part of every child’s early childhood education, will help us recover from COVID-19 and combat continued antibiotic-resistance threats. As Kiran Mazumdar-Shaw has said: “Ultimately, the greatest lesson that COVID-19 can teach humanity is that we are all in this together.”

Fundamentals of infection prevention from the CDC:

• Stay home if feeling sick
• Contact your health provider if you think you have COVID-19 (or any other infection). For COVID-19, use the CDC’s self-checker to help you make decisions and seek appropriate care
• Don’t touch your face with your hands
• Perform frequent hand hygiene — especially before eating, cooking, and after interacting with others or in environments where others have been and using the restroom.
• Clean and disinfect commonly touched and shared surfaces frequency
• When respiratory illnesses are a concern, as is the case with COVID-19, stay six feet apart from other people and wear a face covering. Note: Healthcare staff should follow facility protocols for the use of PPE, including proper donning or doffing

To learn more and keep up with the scientific community on this topic, a new website, Secondary Infections, Antibiotic Chemotherapy and Antibiotic Resistance in the Context of COVID-19, was created to be a resource of peer-reviewed publications, preprints, blogs and commentaries on this very important topic. Additionally, you can read the latest insights from CloroxPro here on CloroxPro.com.

For the latest information on COVID-19 and variants, visit our CloroxPro COVID-19 Hub.