under the microscope
By Rodney E . Rohde , PhD , MS , SM ( ASCP ) CM SVCM , MBCM , FACSc
AMR and COVID-19 : The Intersection of the Pandemic
For the past 15-plus years , I have discussed ( screamed ) about the dangers of empirical antibiotic use in treating infections . Most of us who conduct research in the realm of antibiotic and antimicrobial resistance ( AMR ), understand that there is a time when a physician or others in the healthcare team may need to utilize empirical treatment . For example , if an individual enters an emergency department and are suffering from sepsis leading to organ ( e . g ., kidney ) failure . A physician must start that patient on a broad-spectrum antibiotic to protect their life . Unfortunately , the pandemic and prior has led to patient treatment with antibiotics minus a confirmatory laboratory test to identify the pathogen and the all-important antibiotic susceptibility test to predict effective antibiotic ( s ) use .
The ongoing SARS-CoV-2 pandemic has been at the forefront of everyone ’ s mind , including dominating healthcare and public health . Rightfully and arguably so , it is the most important global health emergency in the last century . However , just under the radar we find that the concern of treating COVID-19 patients may be amplifying an ongoing , slow-burning global pandemic that has been here decades – the antimicrobial resistance pandemic .
In a recent Open Forum Infectious Diseases study conducted in five hospitals in the Johns Hopkins Health System between March 1 , 2020 , and May 31 , 2020 [ Prevalence of Co-infection at the Time of Hospital Admission in COVID-19 Patients , A Multicenter Study ], 1016 adult patients were evaluated for possible bacterial co-infection at time of presentation of COVID-19 . Briefly , recent research tends to show that bacterial co-infection with COVID-19 is uncommon at the time of presentation . However , these data were based on microbiology results only . The investigators sought to develop and apply consensus definitions , incorporating clinical criteria to better understand the rate of co-infections and antibiotic use in COVID-19 . Primary results indicated bacterial respiratory co-infections were infrequent ( 1.2 percent ); one patient had proven bacterial community-acquired pneumonia ( bCAP ), and 11 ( 1.1 percent ) probable bCAP . Two patients ( 0.2 percent ) had viral respiratory co-infections . Yet , and frighteningly so , 69 percent of patients received antibiotics for pneumonia . Most were halted within 48 hours in patients with possible or no evidence of bCAP .
For emphasis , in everyday language this means that seven out of 10 patients were treated empirically with antibiotics when they did NOT have bacterial respiratory infections or bCAP . We can and must do better .
I recently discussed this issue in a Forbes article regarding a recent Bulletin from the WHO . Experts discussed dangers of the ongoing COVID-19 pandemic amplifying antibiotic resistance . Too many people have been receiving antibiotics when presenting with mild cases of COVID-19 , but no pneumonia or even a moderate case with pneumonia . Antibiotics should not be
used here . The article goes on to note that studies “ published on hospitalized COVID-19 patients identified that while 72 percent ( 1,450 / 2,010 ) of patients received antibiotics , only 8 percent ( 62 / 806 ) demonstrated superimposed bacterial or fungal co-infections .” The WHO also reports that azithromycin is being widely used with the hydroxychloroquine treatment as problematic for AMR .
I go on to argue that the recent CDC 2019 Antibiotic Resistance Threats in the United States article , states that despite improvements in recent years , “ the number of people facing antibiotic resistance in the United States is still too high . More than 2.8 million antibiotic-resistant infections occur in the US each year , and more than 35,000 people die as a result . In addition , nearly 223,900 people in the US required hospital care for C . difficile and at least 12,800 people died in 2017 .” Likewise , public health experts from the United Nations , international agencies and others released a report in April of 2019 stating that if no action is taken , “ drug-resistant diseases could cause 10 million deaths each year by 2050 and damage to the economy as catastrophic as the 2008-2009 global financial crisis . By 2030 , antimicrobial resistance could force up to 24 million people into extreme poverty .”
Proactive , prevention of disease is much more cost effective and logical for the treatment of disease rather than being reactive . Simply stated , the nation ’ s ( and world ) public health system has been underfunded for decades . Until we get serious about prioritizing public health in an ongoing , logical , purposeful way , we will continue to fight these deadly causes with fewer people in the public health and medical laboratory spaces . People will be overworked and perhaps rushed on to the “ battlefields ” too soon because of non-sustained pipelines of highly trained professionals in the lean workforce . Cutting funding for new research on vaccines and creative ways of attacking disease will suffer . Cutting educational scholarships and programs for ushering in a new generation of these professionals is shortsighted . Utilizing simulations and modeling to try to prepare better for the next outbreak is critical .
Public health and healthcare funding is smart and pays dividends . It meets the long-standing adage of “ an ounce of prevention is worth a pound of cure .”
Rodney E . Rohde , PhD , MS , SM ( ASCP ) CM SVCM , MBCM , FACSc , serves as chair and professor of the Clinical Laboratory Science Program at Texas State ; associate director for the Translational Health Research Initiative ; as well as associate dean for research in the College of Health Professions . Follow him on Twitter @ RodneyRohde / @ TXST _ CLS , or on his website : http :// rodneyerohde . wp . txstate . edu /