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How covid-19 is accelerating the threat of antimicrobial resistance

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1983 (Published 18 May 2020) Cite this as: BMJ 2020;369:m1983

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Covid-19 in Russia and elsewhere: potential overtreatment and side effects

Dear Editor,

Russia has been the country with the second largest number of COVID-19 cases [1]. 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 [2]. 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 [3] 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” [3].

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 [3].

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) [4] have been discussed previously [5]. 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” [6]. Healthcare responses to COVID-19 may be hastening other public health threats e.g. antimicrobial resistance [7].

References
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

25 May 2020
Sergei Jargin
pathologist
Peoples' Friendship University of Russia
Clementovski per 6-82