Proper use of antibiotics in the COVID-19 era - more relevant than ever
The rapid spread of the coronavirus pandemic, which has infected over 3 million people and causing more than 200,000 deaths to date, has shed light on existing weaknesses and structural problems in healthcare systems worldwide, from poor compliance with infection control procedures to insufficient supplies of medical equipment.1,2
One of the most serious such problems is the threat of antibiotic resistance, which occurs when bacteria adapt in response to medications used to treat infections such as pneumonia, tuberculosis, sexually transmitted infections, urinary tract infections, and wound and skin infections, among other conditions. As the bacteria evolve, they become resistant to these medications, which makes these infectious diseases increasingly difficult to treat.3 For years, the World Health Organization (WHO) and other leading public health organizations have warned that antibiotic resistance, which is caused primarily by the misuse and overuse of antibiotics, is one of the most serious threats facing public health and development worldwide.4 At least 700,000 people die each year from drug-resistant diseases, and the United Nations has warned that this number could increase to up to 10 million deaths per year by 2050.5.6
Now, in the midst of a global pandemic, the threat of antibiotic resistance has become even more serious, according to the Center for Clinical Epidemiology and Outbreaks. Bacterial infections are often major drivers of high fatality rates during viral pandemics due to their increased spread in crowded healthcare facilities, where they afflict already weakened and immunocompromised patients.7,8 Writing in Scientific American, Oxford historian Claas Kirchhelle and his colleagues noted that a large proportion of deaths during the 1918-20 flu pandemic were due not to influenza itself, but to bacterial infections that spread in the hospital wards; similarly, it’s estimated that between 29-55% of deaths associated with the 2009 H1N1 influenza pandemic were actually caused by secondary bacterial pneumonia.7,8 In a study of 191 patients in Wuhan, China, half the patients who died from COVID-19 tested positive for a secondary infection, compared to only one such infection among the patients who survived.9 Furthermore, antibiotic resistance not only decreases the effectiveness of the medications that are urgently needed to fight bacterial infections during a pandemic; resistance itself may increase due to the large quantities of antibiotics prescribed to COVID-19 patients, which jeopardizes effective treatment for a variety of diseases and populations beyond the scope of any one pandemic.9,10
This is an especially serious threat in Greece, due to the country’s already exorbitant rates of antibiotic resistance. Greece has historically had among the highest rates of antibiotic use and resistance in Europe; in a recent survey of antibiotic use of acute-care hospitals in the EU from 2016-2017, the prevalence of antibiotic use in Greece was 55.6%, compared with 30.5% in Europe overall.11,12,13 Greece also has among the highest rates of hospital-acquired infections (HAIs) in Europe, many of which are caused by organisms — known colloquially as “super bugs” — that are resistant to many different drugs.12 The result is that although Greece may have relatively low rates of illness and death due to the coronavirus itself, the country is at an elevated risk of experiencing significant illness and death due to bacterial infections during this pandemic.
Fortunately, the best weapon we have to fight antimicrobial resistance is simple, affordable, and supported by robust evidence: antimicrobial stewardship (AMS), which aims to optimize the use of antibiotics in order to simultaneously prevent the development of resistance and improve patient outcomes.14
Since 2011, the nonprofit Center for Clinical Epidemiology and Outcomes Research (CLEO) has been working to foster the development of AMS in healthcare settings throughout Greece and to reduce both the misuse and overuse of antibiotics as well as rates of hospital-acquired infections.
