Table. Factors that may influence levels of antimicrobial resistance during the COVID-19 pandemic.
| Type of factor | Factors that may favour an increase in AMR | Factors that may favour a decrease in AMR |
|---|---|---|
| Antibiotic use in hospitals | • About 70% of hospitalised COVID-19 patients receive antibiotics [33,34] • COVID-19 patients often receive empiric broad-spectrum antibiotic therapy [34-36] • 16% of hospitalised COVID-19 patients develop a secondary bacterial infection [34], which will necessitate antibiotic therapy • Possible increased use of azithromycin and teicoplanin (because of the initial absence of clear guidelines for the treatment of COVID-19 patients) [4,6,8] • Difficulties in accessing advice from experts before prescribing antimicrobial agents [4] • Antimicrobial stewardship efforts may be undermined because of high workloads and shifting priorities related to COVID-19 [37,38] • Possible aggravation of existing shortages of certain narrow-spectrum antimicrobial agents [39,40] |
• Bacterial co-infection (estimated on presentation) in only 3.5% (95% CI: 1–7%) of COVID-19 patients [33] • Bacterial/fungal infection in only 8% of hospitalised COVID-19 patients vs 11% in non-COVID-19 patients [34]; the percentage for COVID-19 patients may be underestimated because many may have received empiric antimicrobial therapy [41] • Only 1.3% of COVID-19 patients in ICUs, and apparently no patients in other units, developed a healthcare-associated superinfection with antimicrobial-resistant bacteria [19] • Postponed planned surgical interventions result in fewer antibiotic courses for surgical prophylaxis [42] • Fewer emergency and planned hospital admissions [43,44], including chronically ill patients (e.g. oncology patients, diabetic patients, transplant patients), resulting in fewer antibiotic prescriptions |
| Infection prevention and control in hospitals | • Difficulties for HCWs in adhering to standard IPC precautions because of long shifts wearing the same PPE [45] and possible shortages of certain equipment [5] • Focus of HCWs on self-protection (e.g. universal gloving practices) rather than on preventing cross-transmission between patients • In COVID-19 cohort units and ICUs, sessional use of PPE, e.g. long-sleeved gowns that prevent effective hand hygiene [46] and gloves that may not be changed between patients [45] • Overcrowded facilities and possible staff shortages leading to low HCW-to-patient ratios [5] • Shortages of HCWs with appropriate IPC training [4] • Longer hospital stays for COVID-19 patients [5] • Traditional IPC efforts may be temporarily discontinued, including those targeting antibiotic-resistant bacteria, e.g. decreased frequency of screening for carriage of MDROs and difficulties in isolating or cohorting MDRO-positive patients [4,47] • Decreased laboratory capacity to detect AMR carriage, e.g. for processing rapid tests for MDROs, because resources are focused on SARS-CoV-2 diagnosis [4] |
• Isolation of COVID-19 patients with enhanced standard precautions, e.g. increased hand hygiene and use of PPE, plus universal chlorhexidine bathing protocols for patients in ICUs [5] • Increased disinfection of the environment [4,5] • COVID-19 patients are often cohorted in one single unit and cared for by the same group of HCWs [5] • Fewer emergency and planned hospital admissions [43,44], including chronically ill patients (e.g. oncology patients, diabetic patients, transplant patients), resulting in lower colonisation pressure by fewer carriers of MDROs • Fewer transfers from long-term care facilities may lead to fewer cycles between long-term care facilities and hospitals [5] • Construction of new COVID-19 facilities without an established reservoir of MDROs [5] |
| Antibiotic use in the community | • Likely increased antibiotic use in nursing homes and other long-term care facilities • Possible increased self-medication with antibiotics in some countries or regions of the world [48] |
• Possible decreased antibiotic consumption because of fewer patient consultations, e.g. for self-limiting infections that would otherwise have resulted in an antibiotic prescription [4] • Possible decreased incidence of respiratory tract infections as a consequence of decreased person-to-person transmission because of lockdowns, resulting in decreased antibiotic consumption • Possible increased awareness of the difference between viruses and bacteria, and the fact that there are different types of medicines, i.e. antivirals and antibiotics, respectively, for different types of infections [8] • Increased influenza vaccine uptake may decrease the incidence of bacterial superinfections after influenza |
| Hygiene practices in the community | • Increased use of sanitisers and other biocidal agents and their release in the environment [3,6,8,49] | • Increased hand hygiene practices and compliance in the community • Increased physical distancing and use of face masks • Increased disinfection of the environment |
| Cross-border spread | • Fewer patient transfers of seriously ill patients between countries, resulting in less frequent cross-border spread of MDROs • Large decrease in international air travel, resulting in decreasing risk of global dissemination of antimicrobial-resistant bacteria and genes from highly endemic regions [8,50] |
|
| Public health policy making, including One Health | • Shift in high-level policy making towards viral diseases and preparedness for emerging viruses • National plans and other initiatives to fight AMR are likely to have been slowed down, temporarily discontinued or even postponed because of COVID-19 public health emergencies and duties (similar to the WHO Global Strategy for Containment of Antimicrobial Resistance, which was launched on 11 September 2001 and went largely unnoticed by the global community, without any major impact on AMR activities for almost a decade, because of the disproportional focus on biosecurity issues) • Potential One Health impact of increased volumes of antibiotics from prescriptions in humans being released in the environment [3,51] |
• Gain in public and political attention for all threats related to communicable diseases, including already endemic issues such as AMR • Possible decrease in antimicrobial consumption in animals because of reduction in the size of livestock herds [52], possibly combined with difficulties in obtaining antibiotics |
AMR: antimicrobial resistance; CI: confidence interval; COVID-19: coronavirus disease; HCW: healthcare worker; ICU: intensive care unit; IPC: infection prevention and control; MDRO: multidrug-resistant organism; PPE: personal protective equipment; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; WHO: World Health Organization.