Antimicrobial crisis

The Covid-19 pandemic has not only exposed health system challenges but also accentuated other public health crises in countries like Pakistan. With the virus spreading to areas of the world where antibiotic overuse and misuse is common, for example, the threat of a spike in anti-microbial resistance has emerged. In June, WHO Director General Tedros Adhanom Ghebreyesus warned, "The Covid-19 pandemic has led to an increased use of antibiotics, which ultimately will lead to higher bacterial resistance rates."

The recent spike in antibiotic use can be traced to both old unregulated practices and new technological innovations.In countries like Pakistan where antibiotic use was already high, Covid-related symptoms are being excessively treated with antibiotics.

The WHO's interim guidelines on Covid-19 clinical management does not recommend antibiotic treatment for Covid-19 patients with mild to moderate symptoms without clinical suspicion of bacterial infection. Yet, though the risk of secondary bacterial infections such as pneumonia is as low as eight per cent, clinicians are increasingly prescribing antibiotics to prevent this complication. A review of data from mostly Asian countries found that 70pc of patients received antimicrobial treatment despite less than 10pc having a bacterial or fungal infection.

This practice goes hand in hand with the phenomena of overprescribing antibiotics to treat even minor infections (including viral ones for which antibiotics are not effective) and widespread self-medication with antibiotics. Many websites and groups on social media devoted to Covid-19 have been peddling non-medical advice, resulting in the trend of self-medicating with antibiotics gaining momentum. This practice can be controlled by regulating the sale of antibiotics on a prescription-only basis, as well as through increased surveillance by drug inspectors of its sale.

In some countries, even politicians have advocated for the use of azithromycin and hydroxychloroquine in treating Covid-19, despite no conclusive scientific evidence of the effectiveness of these drugs. In fact, what evidence is currently available is overwhelmingly against repurposing these medicines for the virus.

Covid-19 is exacerbating the tendency to overuse antibiotics.

The resultant spike in the use of azithromycin in particular will further exacerbate the antimicrobial resistance crisis. Azithromycin overuse could generate resistance against the antibiotic, complicating the treatment of an entrenched outbreak of extensively drug-resistant (XDR) typhoid in Pakistan. Its overuse during the pandemic should be of paramount concern for public health officials involved in antimicrobial resistance.

The National Institute of Health may also need to revisit treatment guidelines for XDR typhoid fever in light of the prevailing circumstances.

As mentioned earlier, the adoption of new technologies is also leading to an increase in the use of antibiotics. Some studies have found that resorting to telemedicine during the pandemic has led to a rise in overprescribing antibiotics. One study involving the infant population found that antibiotics were prescribed much more often in telemedicine consultations than faceto-face ones.

This practice can be controlled by issuing guidelines on the prudent use of antibiotics for Covid-related symptoms. The issuance of new Covid-related treatment guidelines, and the place of antibiotic therapy within it, should coincide with the ongoing work of developing standard treatment guidelines on the use of antibiotics in general.

Now that the pandemic seems to have momentarily subsided to an extent, this period should be used to reboot the antimicrobial stewardship programmes by incorporating lessons learnt during the first peak of Covid-19 infections.

These lessons should be used to improve health service provider protocols and treatment guidelines for the likely second wave of Covid-19 infections and future epidemics.

The push to promote the prudent use of antimicrobial drugs should not only continue in Covid-affected times but also be propelled forward with renewed determination.