Antimicrobial Resistance Is Growing because of COVID

Antimicrobial Resistance Is Growing because of COVID

Antimicrobial resistance was a major concern for both public health agencies and health care professionals even before the COVID pandemic. In 2019, the latest year for which data are available, antimicrobial resistance led to 4. 95 million deaths globally, making it the third leading cause of death after cardiovascular diseases and cancer.

After more than two years of COVID, with rampant and inappropriate antibiotic use arising from treatment protocols, public health and health care specialists say antimicrobial resistance is getting substantially worse in many countries,. This is concerning because bacteria that cause routine infections in the blood, lungs and uninary tract, not to mention well-known illnesses that still exist in lower-income nations, such as typhoid and tuberculosis, are becoming increasingly resistant to existing drugs. The pharmaceutical industry is not interested in developing new antibiotics because the market is not lucrative. We stand to lose 10 million people each year worldwide by 2050 from diseases that we could once treat. Unfortunately, 90 percent of these deaths will happen in low- and middle-income countries.

Antimicrobial resistance has been a long-standing pandemic of its own that has been overlooked. COVID has made it more urgent to end the culture of liberal antibiotic usage. We must tighten regulations regarding the prescribing of these drugs and train health care professionals around the world to use anitbiotics with greater precision. To prevent the spread disease-causing bacteria, we must improve sanitation and hygiene. We need better diagnostics and more robust vaccine programs. We are running out options and the infectious bacteria that affects so many people in non Western countries is poised to win a war we once had.

Take India, the largest consumer of antibiotics in the world, and a place where the culture of antibiotic use is deeply entrenched. For illnesses such as the common cold, diarrhea, and even short fevers, doctors prescribe antibiotics. These prescriptions are spurred by a variety of factors that include a lack of appropriate knowledge about when to use antibiotics, lack of diagnostics, inability of patients to afford diagnostics, economic incentives, patient demand and fear of clinical failure.

Pharmacists are also a first line for healthcare in many parts India. There are often antibiotics available without the need for a prescription. These drugs are often ineffective because most of the sicknesses are not bacterial but viral. Despite these practices, the public believes that they will.

It is not surprising that India, with its large population and easy access to antibiotics has struggled with widespread misuse of antibiotics. The high number of bacterial infections in India, where antibiotics are needed, is further confusing matters. However, the widespread misuse of antibiotics means that infectious bacteria are developing defenses to these drugs. They are still needed but they are losing their power.

The COVID pandemic has made it more common to misuse antibiotics. Despite COVID being a viral infection with low rates of secondary bacterial infection, the pandemic likely contributed to people in India taking about 216 million excess doses of antibiotics during the first wave in 2020. This was despite the Indian government’s National Treatment Guidelines and World Health Organization (WHO), recommending against antibiotic use for mild and moderate cases of COVID. This practice extended to subsequent COVID surges involving the Delta and Omicron variants, and it has potentially worsened the resistance problem in the country.

India isn’t alone. Researchers have seen similar practices of antibiotic misuse in other countries that are not high-income, including Bangladesh, Pakistan, Brazil and Jordan.

We have discussed several solutions to this problem before, but the most important thing is to change culture – the attitudes and approaches of health care providers and the public towards antibiotics in low and middle-income countries. These nations have high rates of viral infections in the upper respiratory tract. However, most health care providers don’t have national standard treatment guidelines. They are also not user-friendly. This makes it difficult for them to prescribe antibiotics in their daily practice.

Toward this, in 2017, the World Health Organization initiated the AWaRe (Access, Watch and Reserve) framework for antibiotics, which classifies the drugs according to the risk of resistance arising. The WHO will soon release a reference book on antibiotics with simple infographics and a mobile app, which will provide best practices in clinical assessment, diagnosis and treatment of various infections in the outpatient and hospitalized patients using what’s called a traffic-light approach. Recent evidence from China has shown that a traffic-light approach to clinical guidelines for upper respiratory tract infections reduced antibiotic prescribing from 82 percent to 40 percent in the intervention group, compared to 75 percent to 70 percent in the control group.

But, it is difficult to change human behavior and overcome decades of misaligned practice, especially for those who are already practicing doctors, particularly those who work in the informal and private sectors. Mystery client studies, in which trained people visit facilities in the assumed role of clients and then report on their experiences, show a big know-do gap in many countries–a gap between what providers say they would do for a given patient, versus what they actually do in routine clinical practice.

Governments, health systems, and medical professionals will need to do more to stop over-the-counter sales and direct drug sales to people without medical training by pharmaceutical companies. They also need to ban irrational fixed dose combination drugs and work harder against counterfeit medications entering the market. They must also help to establish programs that encourage responsible use of antimicrobials both in hospitals and primary care settings.

India is another example illustrating how regulations can help. The country’s 2018 ban on antimicrobial fixed dose combinations in India has been successful in reducing sales of antibiotics. Similarly, banning over-the-counter sales of antibiotics led to a reduction in antibiotic sales in Brazil and Chile when properly enforced.

In addition to continuing efforts to increase antibiotic utilization among current prescribers, now it is time to train next-generation doctors to be better antibiotic stewards. These drugs are a finite resource that can have a devastating impact on society if they are misused. Medical schools and training programs must teach doctors how to prescribe antibiotics according to standard guidelines. The focus on the next generation of physicians will have a domino impact on the public, pharmacists, and informal health care providers. This will help us to deal with the current antimicrobial resistance pandemic and prevent future ones.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

ABOUT THE AUTHOR(S)

    Sumanth Gandra is an associate professor of medicine at Washington University School of Medicine in St. Louis.

      Madhukar Pai is a professor of epidemiology and global health at McGill University, Canada.

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