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The COVID-19 pandemic has brought in its wake dramatic and stressful changes in our lives. More significantly, we, as health care professionals, have had to adapt and evolve with the changes and learnings during pandemic times. Despite over 40 million cases and 1 million deaths globally, we are yet to understand the full impact of COVID-19, both in terms of managing our patients optimally and the future concerns and challenges, especially with infections and antimicrobial resistance.

During the early days of lockdown in India, it was assumed that the number of non-COVID-19 hospitalisations would decrease, the admissions for chronic diseases would decline and elective surgeries, organ transplantations and attendant interventions would also be fewer. It was also thought that there would be better compliance with infection control practices, including compliance with hand hygiene, antibiotic use would also commensurately come down and intuitively, the challenges of antibiotic resistance would become manageable.

We are facing enormous difficulties in managing COVID-19 patients. But the worst, I believe, is yet to come. A resurgence of cases due to virus mutation or a second wave could be associated with added consequences if our current antimicrobial use continues.

With COVID-19 being a novel infectious disease, we based our management perspectives on knowledge acquired from a century of managing influenza¹. Past fatalities during influenza outbreaks have been due to secondary bacterial infections thus antibiotics were used in most cases of COVID-19. Moreover, co-infections also increased the severity of viral pneumonia. With experience and evidence gained with time, we realised that the management of COVID-19 was predominantly dependent on symptomatic measures. The role of antibiotics remains limited, at best, for severe cases².

Why are antibiotics being increasingly used in the treatment of COVID-19?

There is a lack of data to conclude that COVID-19 is associated with significant bacterial and fungal co-infections³. Yet, there are continually high rates of antimicrobial prescriptions for COVID-19 patients in India. Mild infections in out-patient settings are treated using macrolides and quinolones and in-patients with community-acquired confirmed COVID-19 receive beta-lactams or carbapenems. Diligence in weighing the unintended consequences of antibiotic use is often lacking. In developing countries, antibiotic use is escalating at the expense of good infection control practices, antimicrobial stewardship and surveillance.

I have observed that several issues are leading to an increased use of antibiotics with the management of COVID-19. These are unique to the Indian context if you understand that the antibiotic culture in India is based on an unreasonable dependence on antibiotic use to solve many non-bacterial illnesses. Firstly, there is a lack of robust infection control programs. This has inevitably led to taking the least difficult path of initiating antibiotics. These cognitive biases inherent in human thought processes, especially the ‘Zero-risk bias’, impels us to start antibiotics early. This is aggravated by the lack of antimicrobial stewardship initiatives in many hospitals. There is also a lack of appropriate microbiological investigations before initiation of antibiotics in India. This could be due to constraints of isolation, mobilisation of patients and fear among health care workers that the patients will succumb to bacterial infections, which leads to indiscriminate use of antibiotics. Relying on easily available bio-markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in COVID-19 patients may also lead to errors when used for antibiotic decision making.

Using personal protective equipment (PPE) in humid tropical environments can also impede infection control measures. Moreover, hand hygiene compliance is compromised when double gloving is practised in COVID-19 isolation wards. Staffing these wards with experienced nurses has also been extremely challenging due to a phobia of the SARS-CoV-2 virus. Reduced availability of senior consultants to supervise the COVID-19 wards and advise on antibiotic usage will likely also have a significant impact on antimicrobial resistance.

Despite over 40 million cases and 1 million deaths globally, we are yet to understand the full impact of COVID-19, both in terms of managing our patients optimally and the future concerns and challenges, especially with infections and antimicrobial resistance.

There has been a significant rise in hospital-acquired infections, especially bloodstream infections (BSIs). An increase in rates may be due to lower denominators for central line-associated BSIs (CLABSI). However, a higher number of cases requiring prolonged ventilation and vascular access may predispose to secondary bacterial infections. Choosing the femoral site for lines due to ease of process and remoteness from the respiratory tract may also lead to an increased number of infections⁴. Using catheters with multiple lumens to minimise interventions and facilitate dialysis for renal replacement have lead to an increase in infections. The use of immunomodulators such as steroids and interleukin-6 (IL-6) inhibitors has also increased susceptibility to infection resulting in clinicians resorting to greater antibiotic use for prophylactic purposes. The recent escalation in the use of telemedicine in managing patients, both in the community and in hospitals, may not bode well for antimicrobial usage and resistance, as recent evidence may point⁵.

The difficulty of managing COVID-19 in India

We are facing enormous difficulties in managing COVID-19 patients. But the worst, I believe, is yet to come. A resurgence of cases due to virus mutation or a second wave could be associated with added consequences if our current antimicrobial use continues. Negligence of infection control principles as well as a lack of rationality during these current times of uncertainty may return to haunt us with detrimental effects on infections and antimicrobial resistance.

What we need in India and many other countries during these trying times is effective leadership, intelligent communication, organized infection control as well as antimicrobial stewardship initiatives. It is well recognized that an anxious and agitated mind does not have clarity of thought and rational decision-making skills. We need to improve awareness and education among health care workers and the public so that we remain logical and our antimicrobial prescribing decisions are based on reason.

It was said by George Santayana that ‘those who do not remember the past are condemned to repeat it’. It is essential to regroup and take stock so that we prepare ourselves to face the challenges more responsibly.

References:

1. Morens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: Implications for pandemic preparedness. The Journal of Infectious Diseases. 2008; 198:962-70.
2. World Health Organisation (WHO). Clinical Management of severe acute respiratory infection when COVID-19 is suspected 2020.
3. Rawson TM, Moore LSP, Zhu N, Ranganathan, N, Skolimowska K, Gilchrist M. Bacterial and Fungal Co-infection in Individuals With Coronavirus: A Rapid Review To Support COVID-19 Antimicrobial Prescribing. Clinical Infectious Diseases. 2020; ciaa530 https://doi.org/10.1093/cid/ciaa530.
4. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database of Systematic Reviews 2012;(3): CD004084.
5. Martinez KA, Rood M, Jhangiani N et al. Association between antibiotic prescribing for respiratory tract infections and patient satisfaction in direct-to-consumer telemedicine. JAMA Internal Medicine 2018; 178:1558.