Caregiver and AMR: what has changed during the Covid-19 emergency

AMR: a "silent pandemic" within the pandemic ⁽¹⁾

Antimicrobial resistance (AMR) poses a serious threat to global health. In fact, the incidence, deaths, length of hospitalization and healthcare costs due to AMR are rising sharply. ⁽²⁾

According to a systematic analysis on the global burden of AMR, published in The Lancet, an estimated 4.95 million deaths were associated with bacterial antimicrobial resistance in 2019. Lower respiratory tract infections were the deadliest, responsible for more than 1.5 million AMR-related deaths. The six major pathogens implicated in antimicrobial resistance (Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) jointly accounted for approximately 930,000 deaths. Specifically, the pathogen-drug combination, methicillin-resistant S. aureus, caused over 100,000 deaths, while the other five each lead to about 50,000-100,000 deaths. ⁽²⁾

Understanding the severity of antimicrobial resistance and the key pathogen-drug combinations is crucial for making long-term strategic decisions, especially when implementing programs for infection control and prevention, access to essential antibiotics, and research and development of new vaccines and drugs.  Moreover, it is necessary to improve and scale up microbiology laboratory activities, principally in poorer regions of the world, and implement adequate data collection systems to better understand AMR. ⁽²⁾

Educating caregivers and patients to a One Health approach to antimicrobial resistance ⁽³⁾

Healthcare-associated infections due to antibiotic-resistant bacteria are an increasingly serious challenge to modern healthcare. The irrational use of antibiotics (both by healthcare professionals and patients) leads to increasing the risk of spreading antimicrobial resistance. Even the so-called "antimicrobials of last resort", such as vancomycin, are becoming less and less effective in treating infectious diseases. ⁽³⁾

Education plays a key role in counteracting AMR. In 2018, the Health Education Department of the British National Health Service published a report on education priorities distinguishing two levels: education of medicine and other health profession students and education at community level (schools, non-health professionals, etc.). ⁽³⁾

University education, which is the primary route to preparing healthcare professionals for antimicrobial stewardship, should be strengthened through continuing education programs. Studies also show that high per capita GDP and good education are associated with developing increased resistance, because higher education is correlated with a greater use of antibiotics. Consequently, education to AMR is relevant and should be designed to better inform citizens. ⁽³⁾

The One Health approach to antimicrobial resistance addresses the limitations of generic education, promoting more targeted methods. This process includes various disciplines (medicine, biology, social sciences, education, etc.) which must operate in synergy to achieve better results in the field of public health. In other words, it is a collaborative, multi-sectoral and transdisciplinary strategy in which no sector or organization can tackle the issue of antimicrobial resistance individually. ⁽³⁾

AMR education starting from school is about training well-informed adults who can understand the risk and raise legitimate concerns about overprescribing of antibiotics by doctors or healthcare professionals. ⁽³⁾

Among the various activities put in place from a One Health-AMR perspective, targeting not only students but also the public, child-parent or patient-caregiver interactions offer unique opportunities to reinforce learning on antimicrobial resistance. For example, since children's illnesses are often treated with antibiotics, educational programs on the use of these drugs have also been proposed for parents/caregivers. Both caregivers and children, but also adult patients, need to be educated through easy-to-read interactive training sessions, brochures and printed or electronic educational materials. The main points of focus are: knowledge of infectious agents or microorganisms, their pathways of spreading, prevention and rational use of antibiotics for bacterial - but not viral - diseases. ⁽³⁾

AMR during the Covid-19 pandemic and the patient’s perspective ⁽⁴⁾

To date, the impact of COVID-19 on antimicrobial resistance is a topic of scientific debate and the patient’s "voice" has not yet been analyzed. ⁽⁴⁾

According to a 2021 study published in JAC-Antimicrobial Resistance, regarding patients who had taken antibiotics as part of their treatment for COVID-19 and how much they were aware of antimicrobial resistance, the first evidence of the low levels of AMR awareness came from several COVID-19 patient organizations contacted by researchers. Out of the over 100,000 patients enrolled in this research, only three  were open to discuss antibiotics. Among them, two possessed a scientific foundation and a prior record of antibiotic utilization, while one had resorted to antibiotics as a preventive measure in response to COVID-19 symptoms. Patients also mentioned that they became aware of the potential risks and benefits associated with antibiotics only after they had taken them, as doctors and healthcare professionals provided minimal information. ⁽⁴⁾

The result of the research showed that if patients had better knowledge and awareness of the risks of antimicrobial resistance, they likely would have asked more questions to the doctor. ⁽⁴⁾

AMR and Covid-19: tips for patients and caregivers

Ensuring that antibiotics are administered to COVID-19 patients solely for confirmed secondary bacterial infections is of utmost importance in decelerating the rate of antimicrobial resistance (AMR). Although clinical guidelines and recommendations for healthcare practitioners regarding antimicrobial stewardship practices are available, patient and caregiver viewpoints have been inadequately incorporated. Maintaining transparent communication with them throughout the diagnosis and treatment process constitutes an effective approach.⁽⁴⁾

Patients, healthcare professionals, and the general public play a crucial role in enhancing antibiotic stewardship and reducing antimicrobial resistance. It is significant to recognize that:

• Antibiotics are life-saving drugs, but they are effective only against bacterial infections, not viral ones like COVID-19.
• Patients should carefully monitor their symptoms and consult their physician to confirm a bacterial infection before requesting any antibiotic (and should refrain from requesting antibiotics unless their attending doctor deems it necessary).
• Antibiotics should only be used when prescribed by a doctor.
• When an antibiotic is prescribed, it is essential to follow the treatment instructions.
• Raising awareness and educating friends, families, and communities about the risks associated with antimicrobial resistance and participating in collective efforts are crucial steps in preventing the unnecessary use of antibiotics. ⁽⁴⁾

MC-ID-45-2023