How dealing with antibiotic resistance is entwined with beating COVID-19
Addressing the challenge of excessive use while at the same time assuring sustainable supply of essential antibiotics is key to making health systems resilient to both COVID-19 and antibiotic resistance. The authors explore these interlinked challenges with a special focus on the situation in India.
By Dusan Jasovsky, Jyotsna Singh, and Leena Menghaney
Effective antibiotics are the cornerstone of modern medical practice. The advent of antibiotics significantly increased the chances of surviving serious bacterial infectious diseases. As well, antibiotic therapy has enabled the development of chemotherapy, organ transplantation, surgery in general and a wide range of medical interventions over the past eight decades.
However, in India, poor availability and use of diagnostics, insufficient antibiotic stewardship and compromised infection control both in community and hospital settings result in over-reliance on and over-use of antibiotics. As a result, illnesses usually caused by viruses, such as diarrhoea and acute upper respiratory infections, account for many inappropriate antibiotic prescriptions in community settings.
With an increased focus on antimicrobial resistance (AMR) globally and in India, the Indian Council of Medical Research and other stakeholders have made important steps to introduce antimicrobial stewardship to rationalise antibiotic prescriptions in hospital settings.
The effect of COVID-19
However, according to experts, COVID-19 threatens to undermine these efforts, creating conditions that lead to inappropriate use of antibiotics. The World Health Organization (WHO) is concerned AMR will be further fuelled by the inappropriate use of antibiotics during the COVID-19 pandemic.
Broad-spectrum antibiotic use and overuse is common among COVID-19 patients, and prescribing is often based on clinical presentation rather than laboratory test results. Besides that, differentiation between bacterial and viral pneumonia can be difficult even with availability of laboratory tests, particularly for severe cases.
Only a small proportion of COVID-19 patients may need antibiotics to treat bacterial infections. WHO has issued guidance specifically to not provide antibiotic therapy or prophylaxis to patients with mild COVID-19 or to patients with suspected or confirmed moderate COVID-19 illness unless there is a clinical indication to do so.
Beyond this, there are also risks of acquiring healthcare-associated infections in COVID-19 clinical contexts due to patients undergoing long hospital stays and invasive medical procedures, such as invasive ventilation and indwelling catheters. This underlines the importance of keeping antibiotics working for the management of people with severe COVID-19.
Integrating stewardship into pandemic response
It is therefore important for countries like India to introduce evidence-based guidelines to define when to use antibiotics in COVID-19 patients and to encourage treatment providers to follow the principles of antibiotic stewardship.
Also crucial is making diagnostic tests available to help identify bacteria and their resistance patterns. This includes bacterial cultures, antibiotic susceptibility testing, and differentiating simple COVID-19 infections from those including co-infections or an alternative diagnosis (like imaging, procalcitonin, etc).
In low-resourced settings, laboratory capacity is often a challenge. With labs responding swiftly to the COVID-19 pandemic, they are shifting their limited capacities to COVID-19 testing and deprioritising cultures and antibiotic susceptibility testing. As a result, not enough cultures are being sent for confirmation for the presence of secondary bacterial or fungal infections in COVID-19 patients.
What’s needed today are concrete measures such as systematic testing of severe COVID-19 patients with suspected bacterial co-infections, in order to better integrate antibiotic stewardship into the pandemic response.
The increased focus on COVID-19 and pandemic-related restrictions have also affected AMR surveillance and training. These aspects have to be preserved and strengthened. Proper microbiology diagnostic capacity would support surveillance of antibiotic resistance, as well as provide better-targeted individual patient care. Health systems would thus be able to monitor the AMR threat that lurks behind the COVID-19 pandemic.
In addition, monitoring of antibiotic consumption is another essential component of proper antibiotic stewardship. For example, one review of studies showed that while 72% of hospitalised COVID-19 patients received antibiotics, only 8% had bacterial or fungal co-infections.
This exposes the need to monitor local antibiotic-prescribing trends to inform sound stewardship practices in COVID-19 clinical management, while reviving the international discussion on the void in the antibiotic innovation pipeline.
Success means achieving sustainable access
Besides the issue of excess, there is an often-overlooked access issue.
As we pointed out a year ago in our article depicting an access issue in AMR, the current pharmaceutical market in India promotes “increases of consumption rates of last-resort antibiotics. The pharmaceutical industry does not see profit in producing relatively inexpensive ‘Access’ group antibiotics, while drugs that guarantee higher pay offs (often from the Watch and Reserve group) are ensured a reliable supply.”
This is however in direct contrast with the WHO’s strategy, which calls for ‘Access’ group antibiotics to make up more than 60% of overall antibiotic use.
The access crisis in ‘Access’ group antibiotics has been further accentuated by the trend of consolidation or withdrawal of manufacturing capacity of active pharmaceutical ingredients (API) used for the production of antibiotics. With few actors in the production and supply chain due to limited market size and low profit margins among other reasons, the supply chain of these medicines remains unstable.
The Indian drug regulatory authority’s reaction to impose export restrictions on API (including those for antibiotics) during the COVID-19 pandemic, in order to deal with possible domestic shortages, could have further threatened continuity of supply. This threat was headed off however, with the government having since lifted the restrictions.
International cooperation needed to manage scarce resources
Managing and mitigating the risks associated with the competition for scarce resources during a pandemic and beyond, such as essential antibiotics, requires international cooperation and global solidarity.
Without international mechanisms to achieve sustainable access to novel and existing antibiotics, there remain many challenges for both low- and middle-income countries and high-income countries that can be efficiently addressed only in a collaborative way.
→ Increasing diversification of manufacturing capacities
→ Improving transparency and forecasting across distribution lines
→ Establishing collaborative pooled procurement mechanisms and initiatives among UN agencies, Member States, global procurers and other stakeholders to mitigate shortages
→ Introducing international platforms with access conditions and stewardship measures that countries could subscribe to in order to access relevant antibiotics sustainably.
With weak spots in health systems and public health capacities in many countries, addressing the challenge of excessive use while at the same time assuring sustainable supply of essential antibiotics is key to making health systems resilient to both COVID-19 and antimicrobial resistance.
The article was originally published in Down to Earth magazine during World Antibiotic Awareness Week 2020 and contains minor amendments.