AMR in the post COVID-19 world

In 2019, the estimated number of deaths associated with bacterial antimicrobial resistance (AMR) was close to 5 million. ⁽¹⁾ Despite this concerning global scenario, it should be highlighted that in some regions of the world, healthcare-associated infections (HAIs) were reported to be decreasing owing to improvements and optimization of infection-control practices and antimicrobial stewardship interventions. ⁽²⁾ These encouraging results in some parts of the world are now at risk of being undermined or lost by the significant impact of the coronavirus (COVID-19) pandemic and its effect on epidemiology of AMR and HAIs. 

Data reported to the US National Healthcare Safety Network (NHSN) show a significant increase in central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator-associated events (VAEs), and bacteraemia due to methicillin-resistant Staphylococcus aureus (MRSA) after the advent of the COVID-19 pandemic. ⁽³⁾ 

Additional data suggests that the risk of HAIs due to Gram-negative bacteria with difficult-to-treat resistance (GNB-DTR), increased during the pandemic especially with prolonged length of hospital stay. ⁽⁴⁾ 

This worrisome scenario is likely the consequence of a combination of different factors: 

• the use of antibiotics (up to >90% in some cases) in patients with severe COVID-19 at hospital admission despite the true rate of concomitant bacterial infections being very low, owing to the atypical clinical presentation of COVID-19  that can resemble bacterial sepsis 
• the difficulties in guaranteeing sufficient infection-control measures to prevent cross transmission of resistant pathogens between patients in overcrowded hospitals during the peaks of the pandemic
• the redeployment of experts in infection-control and antimicrobial stewardship to other tasks during the COVID-19 emergency 
• the need for prolonged care during recovery from COVID-19 for some patients, that may continue to expose patients to the risk (albeit reduced) of resistant infections while recovering ^(4-7) 

The combination of all these elements further stresses the need to recalibrate our approach to AMR based on the positive results obtained in some regions up to 2019. 

All of this would involve several interventions. The first is that of not only to improve, but also to develop specific antimicrobial stewardship recommendations for dramatically reducing the empirical use of antibiotics in patients with COVID-19. Notably, this would have implications for patients with COVID-19, since avoiding overuse of antibiotics will also reduce environmental selective pressure for resistance, thereby providing indirect beneficial effects also to other patients (by reducing their risk of acquiring colonization by resistant organisms). The second aspect would be to guarantee adequate adherence to infection-control measures by exploiting the increased awareness (generated by the pandemic), of the absolute importance of effectively controlling the spread of infections.

In the long term, only a firm, global and concerted approach to AMR would prevent the post-COVID-19 world from colliding with a worrisome post-antibiotic era.

Written by Daniele Roberto Giacobbe, Assistant Professor of Infectious Diseases (University of Genoa)

MC-ID-41-2022