Has There Been Exacerbation of Disparities in Antimicrobial Resistance during the SARS-Cov-2 Pandemic?

Global disparities in care experienced during the coronavirus disease 2019 (COVID-19) pandemic may exacerbate other health inequalities with lasting effects long after the pandemic has abated. The COVID-19 pandemic has brought many changes to our lives with both individual as well as institutional changes. Across countries, a substantial inequality in COVID-19 management has occurred including access to personal protective equipment (PPE), treatment availability (including essentials such as oxygen), and vaccine access. The long-term effects of the COVID-19 pandemic are yet unknown, but one concern is the risk or worsening of antimicrobial resistance (AMR). It is important to recognize and mitigate such risks. The aim of this commentary is to discuss potential ways in which the COVID-19 pandemic has exacerbated AMR and disparities in AMR management.

The risk for AMR exacerbation during the pandemic is not a uniform risk. Rather, the pandemic likely exacerbated pre-existing disparities. Institutions with higher resources pre-pandemic may have been better able to maintain institutional policies and measures to monitor and track infections, antimicrobial stewardship (AMS), and antibiotic use. Institutions with fewer resources likely were unable to maintain surveillance programs. Environments where there is poor compliance with infection prevention and control measures likely saw heightened infections. Finally, vaccine availability and acceptance also influence risk for AMR worsening. Vaccine coverage has been shown to decrease the overall number and severity of COVID-19 infections. As such, these patients are less likely to receive or need empiric antibiotic coverage.

Antibiotic agents are indispensable to modern healthcare with multiple studies documenting the importance of early and appropriate antibiotics in saving lives and improving outcomes. ¹ However, antibiotic agents need to be used judiciously because indiscriminate use and abuse of antibiotic agents leads to AMR. Surgeons are directly impacted by AMR as is may influence choice of prophylactic peri-operative antibiotics^2,3 or treatment regimens in patients with infections. Antimicrobial resistance is a threat to high resource settings (such as the United States) because antibiotic options in the drug development pipeline are limited, ⁴ but AMR is also a menace in low- and middle-income countries, where there are fewer choices of antibiotic agents available. ⁵

Control and monitoring of antibiotic use and AMR are complex and challenging in even the best of situations. At the individual level, physicians and patients discuss the need for antibiotics. At an institutional level, AMS and infection prevention and control committees exist. Beyond institutions, state, country, or regional regulations may include monitoring for antibiotic agents in animals or the environment. Each of these measures requires material resources, time, and money. These resources are often in short supply, especially in resource-limited settings. As a result, sites with the lowest resources may have greater challenges controlling AMR.

To date, limited data exist on the association between the COVID-19 pandemic and AMR development. Several institutions have shown an increase in overall healthcare associated infections during the pandemic, with the greatest increases seen in central line infections, ventilator-associated infections, and invasive mold infections. ⁶ The data on AMR, however, are more limited. One study found no difference in antibiotic susceptibility in pathogens causing ventilator-associated pneumonia during the pandemic compared with pre-pandemic. ⁷ In a single-institution study of hospitalized patients with COVID-19 in Italy, there was a higher incidence of blood stream infections due to multi-drug–resistant organisms compared with historical controls. ⁸ In a single-center study comprising 494 bacterial isolates obtained from patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) admitted to the intensive care unit of a tertiary care hospital in Delhi, India, there was a 40% increase in AMR among isolates obtained during the COVID-19 pandemic compared with pre-COVID-19 times. ⁹ Data from other regions are more limited.

The pandemic has brought many challenges that are likely to reduce development of AMR. With the concern for spread of the virus, more extensive cleaning practices have been enacted throughout hospitals around the world. There has been increased focus and implementation of hand hygiene and infection prevention measures. Businesses, institutions, households, and individuals are also more aware of the transmissibility of disease. There has been implementation of lockdowns, social distancing measures, and reduction in a wide variety of activities, limiting personal interactions. This result of less inter-personal interactions may limit the spread of disease. With decreased spread of bacteria, there are fewer drivers of AMR. However, to our knowledge, there has been no study evaluating the association between social distancing and AMR.

Unfortunately, many of the changes because of the pandemic have been counterproductive toward management of AMR. Many institutions have been unable to maintain institutional practices such as AMS programs and infection control monitoring practices. A questionnaire was designed and disseminated to AMS leads in the United Kingdom and most (64%) respondents reported that COVID-19 had a negative impact on routine AMS activities. ¹⁰ Similarly, in a questionnaire of World Health Organization Global Antimicrobial Resistance and Use Surveillance System national focal points, 67% respondents reported a limited ability to work with AMR partnerships. ¹¹ Reduced availability of nursing, medical, and public health staff for AMR was reported by 71%, 69%, and 64%, respectively. ¹¹ Activities reported to have been negatively affected by the pandemic included audit, quality improvement initiatives, education, AMS meetings, and multidisciplinary work. ¹⁰ Other challenges included decreases in funding, especially in low- and middle-income countries. ¹¹ While the importance of AMS programs on reducing AMR is acknowledged,^12,13 no study has evaluated whether disrupted AMS programs are associated with worsened AMR.

Despite the fact that COVID-19 is a viral disease, increased consumption of antibiotic agents has occurred due to a concern for bacterial superinfection in patients with COVID-19. ¹⁴ The identification of bacterial pathogens is challenging in low- and middle-income countries in particular because of the limited diagnostic tools available to discriminate between bacterial and viral infections. ¹⁴ The use of antibiotic agents in the community during the pandemic is understudied at this time.

Both COVID-19 and AMR are global problems, and we need to work together to find solutions. Just as incomplete control of COVID-19 led to a global threat with development of a new variant, incomplete control of AMR can lead to global threats with resistant pathogens for which no treatment exists. Therefore, it is imperative that access to resources, medications, and vaccines are available for all countries. We recommend that national and international organizations work together to ensure equity in access to these critical resources. It is in the self-interest of high-resource countries to support and partner with low-resource countries to ensure control and elimination of antimicrobial resistant pathogens and COVID-19 before new variants or resistance genes develop.