Some public health experts seem quite worried that the misuse or the overuse of antibiotics amid the pandemic might end up exacerbating a different crisis that has been going on in the background, namely antibiotic resistance, which involves pathogens such as bacteria or fungi evolving to be able to evade strong medication meant to get rid of them.
Every year, over 750,000 people lose their lives as a result of antibiotic-resistant infections but this number, as high as it may appear now, is expected to rise up to 10 million by 2050!
In fact, only in the United States, antibiotic-resistant microbes cause over 2.8 million infections as well as more than 35,000 deaths every single year.
And what may be making this issue even worse is the overuse of antibiotics during the pandemic!
When COVID-19 first appeared, during the first few months of the pandemic, many patients who showed up with fever, coughing, shortness of breath and white spots on their lungs identified after an X-ray, were generally prescribed antibiotics.
For example, in the United States, over half of the almost 5,000 patients hospitalized between the months of February and July, 2020, were prescribed an antibiotic or more within the first 48 hours of admission.
Jacqueline Bork, a University of Maryland Medical Center infectious disease physician, states that “When you deal with uncertainty, you end up on the side of the prescribing, which is not necessarily the right thing to do.”
It is a known fact that antibiotics are able to kill bacteria but are not at all useful against viruses such as SARS-CoV-2, which is what causes COVID-19.
However, since pneumonia can be caused by bacteria, fungi as well as viruses, it takes at least 48 hours to actually identify the cause and to do that, more invasive procedures are sometimes needed.
Sometimes, the tests are not even able to confirm the exact cause.
Bork mentions that “Many of us were overprescribing a good amount of antibiotics, probably. But without a firmer understanding of what we were dealing with, we did the very best we could at the time.”
Some medical experts were also worried that a bacterial or fungal infection could appear either during or after a COVID-19 infection, similar to what they had seen in other viral diseases as well, such as influenza.
Bork explains that “In the beginning, there were many people that came in with pneumonia that we could not even test for viral versus bacterial infection.”
She and other physicians like her from all over the world have learned that bacterial and fungal co-infections actually only occur in less than 20% of all COVID patients.
This, as a result, has led to cutting down antibiotic use.
Even so, for patients who were seriously ill and needed to remain in the hospital for a longer period of time, oftentimes with catheters and breathing tubes that can cause sepsis-resulting bacterial infections, antibiotics were still recommended.
With that being said, it’s safe to say that in many parts of the globe, medical experts still prescribe antibiotics to COVID-19 patients who might not really need them.
At the same time, many people, unable to check in with a physician self-medicate with antibiotics, even as a preventive measure sometimes!
All that being said, the lack and high cost of diagnostic tests to confirm bacterial infection and a justified need for antibiotics as well as other factors such as a preventive mindset (just in case) and not being completely in tune with the latest science, may have led to the misuse and overuse of antibiotics throughout the COVID-19 pandemic.
So how does antimicrobial resistance develop?
Some bacteria and fungi are able to naturally produce chemicals we have come to know as antibiotics that are able to either inhibit or kill the growth of other bacteria fighting over limited resources.
In time, the targets, however, grow able to adapt and evolve, becoming resistant to the medication by producing proteins known as enzymes that in turn inactivate the antibiotic, restrict the antibiotic’s entry, drain the medicine from bacterial cells or just completely bypass its effects.
At times, other bacterial species that were not originally the target of the antibiotics could also develop defenses by simply acquiring the relevant genes from surrounding bacteria via a process known as horizontal gene transfer.
While scientists have used natural antibiotics as a model to create their own commercial ones to fight bacterial infections, it is likely that some of those bacteria that cause infections that started in water and soil have evolved genes that give them resistance already.
At first, such resistant bacteria form a rather small form of proportion of the population in the host body but with increased use of antibiotics, that tends to change.
The medication attacks and destroys susceptible bacteria eliminating competition and letting the resistant microbes reproduce and thrive quickly.
Furthermore, administering incorrect doses of antibiotics or using them inappropriately such as for the wrong disease, can actually destroy good bacteria in the human body, resulting in the establishment of “superbugs,” which are quite resistant to many antibiotics out there.
This kind of drug-resistant bacteria is able to spread in communities, hospitals, among poultry and livestock farms through sewage, surfaces, contaminated water and food, as well as through direct contact!
In other words, more people having these so-called superbugs and antibiotics becoming more and more ineffective could lead to higher medical costs, prolonged hospital stays, and more deaths.
All of this is especially worrying for low and middle income nations all over the world which are generally disproportionately impacted because of limited access to quality healthcare, sanitation and clean water as well as over the counter access to antibiotics and more – reasons that can contribute to a higher practice of self-medication, especially if consultation is expensive.
But how does COVID-19 contribute to exacerbating multi-drug resistant infections?
According to a global survey done by the World Health Organization towards the end of 2020, no less than 35 out of 56 countries reported an increase in antibiotic prescribing during the pandemic.
In one country, medical experts even prescribed antibiotics in almost all COVID-19 cases while in another, there was a serious self-medication tendency reported.
The most prescribed antibiotics to hospitalized COVID-19 patients have been fluoroquinolones, cephalosporins, azithromycin, doxycycline and carbapenems.
These are commonly used broad-spectrum antibiotics able to destroy a few different kinds of bacteria including beneficial ones even though many studies have shown that fungal or bacterial co-infections or secondary infections account for less than 20% amongst COVID-19 patients.
And that’s not all! Outpatients have often been prescribed antibiotics such as azithromycin and doxycycline as well, even those with very mild symptoms.
At the start of the pandemic, several studies also recommended the use of azithromycin and doxycycline thanks to their anti-viral and anti-inflammatory properties that seemed able to calm down COVID patients’ hyperactive immune system at a point where it may begin to attack its own cells.
Despite this attempt however, newer research has proven that there were no actual benefits to these recommendations.
A pulmonologist from the P.D. Hinduja Hospital in Mumbai, India, by the name of Lancelot Pinto, explains that “A lot of COVID-19 patients see me for a second opinion, and even now I see azithromycin on their prescriptions. Maybe the justification is that possibility of a bacterial infection, so better to be covered, but I do not think a lot of physicians [in India] care whether it is a virus or not when it comes to just prescribing antibiotics.”
In other situations, doctors also felt the need to prescribe azithromycin, especially in rural areas, for instance, due to a lack of access to diagnostic tests like X-rays to confirm pneumonia, let alone to be able to identify whether the case of it is fungal, bacterial or viral.
A pathologist from the Aga Khan University in Karachi, Pakistan, Rumina Hasan, states that “When people are not as confident, the thought is that it is better to give it, just in case, why take the risk.”
Hasan also points out that overuse or inappropriate use of antibiotics amid the pandemic has stemmed from medical specialists being unable to keep up with the latest information on COVID as well.
“And once you establish a trend [of using certain drugs against a disease] it is really hard to change it,” Hasan mentions.
When used right, antibiotics can really save lives but health experts from all over the world think that easy access to them and inappropriate use during the pandemic might have really caused the perfect situation for the spread of resistant bacteria.
Regional advisor on antimicrobial resistance at the Pan American Health organization, Pilar Ramon-Pardo, mentions that while we may not yet notice the rise of superbugs and the consequences at this time, “the damage is done.”
During the pandemic, there has been a struggle to collect samples and to report on such drug-resistant microbes, The Global Antimicrobial Resistance and Use Surveillance System, launched by the WHO back in 2015, also taking a hit.
There is also a lot of mental fatigue and a budget problem since all resources have been redirected to fight off COVID-19.
Professor of biomedical engineering at Boston University, Muhammad Zaman, states that “People aren’t interested in hearing about yet another public health crisis. Something has got to give.”
So does the rise of antibiotic-resistant infections after the pandemic mean the creation of other, new antibiotics that can fight these infections?
Zaman stresses that while that could be the logical step, chances are there aren’t going to be many!
The reason is that antibiotic courses very rarely exceed 14 days and they also do not get pharmaceutical companies the same type of profits as therapeutics for chronic diseases, including cancer and diabetes.
Not to mention that these hypothetical new drugs are likely to find drug resistance quite quickly, which, once again, makes investing in such a project, not as lucrative.
With that being said, however, back in 2013, the National Institutes of Health launched a program focused on antibacterial resistance in order to conduct and fund important studies meant to test new medication and diagnostic tools but also optimize the right use of already available antibiotics on the market.
As far as health experts all over the world are concerned, the solution involves improving the prevention and the control of infections.
Another hope is the development of vaccines against drug-resistant pathogens.
Zaman goes on to mention “But the notion that this is a purely science problem is incomplete and inaccurate. We have to think about economics, access, and human behavior.”
