How covid-19 is accelerating the threat of antimicrobial resistanceBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1983 (Published 18 May 2020) Cite this as: BMJ 2020;369:m1983
All rapid responses
Antimicrobial resistance has become a global concern over the course of the years. Unfortunately, it is becoming a major threat during the COVID-19 pandemic. Considering the prevailing conditions, the World Health Organization has provided clear antibiotic stewardship principles about the use of antibiotics. WHO states that antibiotics cannot kill viruses, they can only be used to treat bacterial super-infections in COVID-19 patients.
In third world countries like Pakistan antimicrobial resistance is a matter of grave concern because the literacy rate is quite low. In a country where a major chunk of the population cannot read or write, the term “antibiotic resistance” seems quite alien. So, educating the masses about antimicrobial resistance is no doubt challenging yet the need of the hour. This lack of awareness has led to self-medication and extensive use of unprescribed antibiotics during the pandemic. The social stigma associated with the disease has also heightened in Pakistan which is adding fuel to the ‘fire of resistance’. People associate the disease with particular ethnic and religious groups. Misinformation and conspiracy theories also play a role in weakening the status of corona virus as a real threat to mankind. Thus, individuals tend to hide their symptoms and refuse to get tested. They resort to self-dosing of broad-spectrum antibiotics even for treating mild symptoms oblivious of the fact that this is rendering bacteria more resistant.
Recently, EU JAMRAI held an antibiotic resistance symbol making competition in order to educate people and highlight the issue globally. Pakistan and other third world countries should also focus on carrying out such awareness activities to call attention to this serious matter. Public health care experts should unite to bring clarity on this issue and make the laymen aware of misuse of antibiotics and future risks that it can impose. Keeping in view the low literacy levels, this can be done by explaining such scientific problems in native languages and simpler terms. A psychological study shows that people tend to be more responsive towards concepts explained in their native language. th importance of expert medical advice should be promoted. Self-medication should be highly discouraged particularly for COVID-19 and generally for all kinds of diseases. While the masses are being educated about hand hygiene and social distancing, it is high time that government and health care professionals join hands to help communities determine the severity of antimicrobial resistance too. If this situation is not handled diligently, we might win the battle of COVID-19 but we will be left unarmed against resistant pathogens in the years to come.
1. Getahun H, Smith I, Trivedi K, Paulin S, Balkhy HH. Tackling antimicrobial resistance in the COVID-19 pandemic. Bull World Health Organ. 2020;98(7):442-442A. doi:10.2471/BLT.20.268573
2. Akhund R, Jamshed F, Jaffry HA, Hanif H, Fareed S. Knowledge and Attitude of General Pakistani Population Towards Antibiotic Resistance. Cureus. 2019;11(3). doi:10.7759/cureus.4266
3. Rather IA, Kim BC, Bajpai VK, Park YH. Self-medication and antibiotic resistance: Crisis, current challenges, and prevention. Saudi J Biol Sci. 2017;24(4):808-812. doi:10.1016/j.sjbs.2017.01.004
4. How denial and conspiracy theories fuel coronavirus crisis in Pakistan | Asia| An in-depth look at news from across the continent | DW | 23.06.2020. Accessed July 16, 2020. https://www.dw.com/en/how-denial-and-conspiracy-theories-fuel-coronaviru...
5. Antibiotic Resistance Symbol Contest - JAMRAI. Accessed July 16, 2020. https://eu-jamrai.eu/symbol-contest/
6. Caldwell-Harris CL. Emotionality differences between a native and foreign language: Theoretical implications. Front Psychol. 2014;5(SEP). doi:10.3389/fpsyg.2014.01055
Competing interests: No competing interests
Russia has been the country with the second largest number of COVID-19 cases . All housemates of infected individuals undergo self-isolation initially for 14 days with a strict stay-at-home order. The physical distancing restrictions are unfavourable especially for aged people . Nasal swabs are taken sometimes with excessive force, causing mucosal damage, which can predispose to secondary infections.
Furthermore, 2 text fragments from the official recommendations on COVID-19  should be commented on.
Page 55: “Indications to the tracheal intubations (one of the following criteria suffices): hypoxemia with oxygen saturation according to pulse oximetry SpO2 < 92% despite the high flow oxygen delivery in the prone position; respiratory rate > 35 breaths per minute; increase in the visible thorax respiratory excursions; derangement/change of consciousness; deterioration of the visualized picture of the lung; apnea; unstable hemodynamics” .
Pages 106-107 (shortened): a patient testing positive for COVID-19 must be hospitalized in the presence of one of the following criteria: respiratory rate ≥ 22; SpO2 <93%; mild course of the disease in a patient > 65 years old OR in combination with a respiratory disease (bronchial asthma, COPD), chronic heart failure or diabetes mellitus .
There is an opinion among physicians that intubation has been overused in COVID-19 patients in Russia. Other examples of over-manipulation e.g. bronchoscopy in young patients (1478 procedures in 977 patients diagnosed with community-acquired pneumonia)  have been discussed previously . The same is probably true for China, where the literature stresses concerns about non-invasive ventilation because of “aerosolisation of the virus… so it is commonly not recommended. Therefore, these authors and many others have come to a reasonable conclusion that it is best to intubate earlier in the disease progression” . Healthcare responses to COVID-19 may be hastening other public health threats e.g. antimicrobial resistance .
1. Dyer O. Covid-19: Cases rise in Russia as health workers pay the price for PPE shortage. BMJ 2020;369:m1975.
2. Jargin SV. COVID-19: economic damage is a health risk. Am J Prev Med Public Health. 2020;6(3):62-64.
3. Kamkin E.G. Vremennye metodicheskie rekomendatsii. Profilaktika, diagnostika i lechenie novoi koronavirusnoi infektsii (COVID-19) [Temporary methodical recommendations. Prevention, diagnostics and treatment of the new coronavirus infection (COVID-19)]. Version 6. Moscow, 28 April 2020.
4. Kazantsev VA. The use of bronchological sanation for treatment of community-acquired pneumonia. In: Abstract book. 3rd Congress of European region. International Union against Tuberculosis and Lung diseases (IUATLD). 14th National Congress of Lung diseases; 2004 June 22-26; Moscow; p. 361.
5. Jargin SV. Invasive procedures with questionable indications: Prevention of a negligent custom. J Surg Open Access 2017;3(5).
6. Aziz MF. The COVID-19 intubation experience in Wuhan. Br J Anaesth. 2020; doi:10.1016/j.bja.2020.04.058
7. Hsu J. How covid-19 is accelerating the threat of antimicrobial resistance. BMJ 2020;369:m1983.
Competing interests: No competing interests
The problem highlighted in the article is genuinely alarming. It has added its bit to the prevailing large scale and indiscriminate use of antibiotics, not only for treatment of other human and animal diseases, but also in animal food production systems. The tools for emergence and spread of antibiotic resistance and ‘resistome’ analysis are available and are making some predictions as well [1, 2].
To add to the problem of AMR emergence, large scale use of disinfectants and sanitizers in the wake of Covid-19 pandemic is affecting the microbiomes of various ecological niches in humans, animals and environments. ‘Dysbiosis’ in host-commensal interrelationships is the likely outcome of such practices, thereby impacting immune functioning, metabolism, physiological parameters and host’s susceptibility to various infectious and non-infectious diseases . Alcohol resistance (resistance to 70% ethanol or isopropanol in hand disinfectants or sanitizers in healthcare premises) in Enterococcus faecium, a nosocomial pathogen and its vancomycin resistant strains (as superbugs) has recently been reported . The dilemma is that in fighting against one i.e., Covid-19 pandemic, we face collateral damage by losing several commensals and possibly creating space for newer threats. I think, we should be prepared for the future with tools that allow forecast or predictions about the newer threats.
Prebiotics, probiotics, immunobiotics, synbiotics, etc. are promising correctives for dysbiosis, with some evidence existing . But I see the scale of the current problem of excessive use of disinfectants much larger than for mere personal hygiene and sanitation in such events as 'panic use of sprays of sodium hypochlorite on people and premises alike', clinics and hospital premises, entire campuses, hotels, trains, buses, aeroplanes, houses or to name anything! And it has been continuing and is likely to continue for several weeks around the world.
Therefore, I believe that it is not only a concern of emergence of resistance or tolerance to antimicrobials, disinfectants and sanitizers, but also of ‘wiping’ of several microbiota in various ecological niches with the impact unpredictable so far. Our tools and the times to come would hopefully reveal that loss. Till then, we should be guided by the prevailing wisdom of (excessive) use of sanitizers, disinfectants for hands and places, for both practical and psychological cleansing, and indiscriminate use of antibiotics for the secondary infections in Covid-19 patients, waiting for a vaccine and/or specific antiviral agent(s).
1. Mahnert A, et al. Man-made microbial resistances in built environments. Nat Commun 10 (2019), 968.
2. Crofts TS, Gasparrini AJ and Dantas G. Next-generation approaches to understand and combat the antibiotic resistome. Nature Rev Microbiol 15 (2017), 422-434.
3. Lynch JB and Hsiao Y. Microbiomes as sources of emergent host phenotypes. Science 365(2019), 1405-1409.
4. Pidot SJ, et al. Increasing tolerance of hospital Enterococcus faecium to handwash alcohols. Sci. Transl. Med. 10(2018), eaar6115.
5. Zelaya H, et al. Respiratory antiviral immunity and immunobiotics: Beneficial effects on inflammation-coagulation interaction during Influenza virus infection. Front Immunol 7 (2016), 633.
Competing interests: No competing interests