According to research conducted by WHO/Europe and reports from the field, the European Region now risks accelerated spread of antimicrobial resistance. The long-term problem of antibiotics being used inappropriately by individuals and in health care settings is worsening as a result of the COVID-19 pandemic. This year’s World Antimicrobial Awareness Week, set to take place on 18–24 November, is an opportunity to focus attention on the evolving situation.
Despite the fact that antibiotics do not treat or prevent viral infections like COVID-19, the results of behavioural insight research conducted in 9 countries and areas of the European Region showed antibiotic use increasing throughout the pandemic along with cases. Of those taking the antibiotics, 79–96% reported not having been infected with COVID-19 but were taking antibiotics inappropriately, believing they would prevent infection. Evidence indicates that up to 15% of severely affected COVID-19 patients develop bacterial co-infection and could need antibiotics, whereas 75% actually receive them.
“Antibiotics save lives and we should ensure their effectiveness for as long as possible. Some patients with severe COVID-19 also have bacterial co-infections and need antibiotics to survive,” explained Dr Nino Berdzuli, Director of WHO/Europe’s Division of Country Health Programmes. “This has been a very difficult time for health care institutions. Especially now in the pandemic it is important that clear guidelines are put in place to prevent inappropriate use of antibiotics. Everyone has a role to play as an antibiotic guardian, whether they are a parent, a prescriber or a policy-maker.”
Dr Fabio Soldani is an infectious disease specialist in Verona, Italy, consulting on different wards within the Azienda Ospedaliera Universitaria Integrata hospital. His experience on the front line in northern Italy – the first area of Europe to be severely affected by COVID-19 – confirms how difficult it was at first to restrict the use of antibiotics.
Keeping antibiotics for patients with clear signs of bacterial infection
“At the beginning, we gave COVID-19 patients in my hospital antibiotics in the way that we typically would for community-acquired pneumonia. This meant we would give them broad-spectrum antibiotics such as cephalosporins and azithromycin, until possible bacterial superinfections had been ruled out,” he explained. “As the epidemic continued and we gained more experience, we started reserving antibiotic treatment only for patients with signs of laboratory-confirmed bacterial infection. Whenever possible, we tried to shorten the length of antibiotic treatment.”
In Dr Soldani’s hospital good practice in antimicrobial stewardship from before the pandemic helped prevent antibiotic misuse when the crisis hit.
“In intensive care we generally avoid giving antibiotics to prevent bacterial infection in patients on machines that are helping them to breathe. We kept this practice also during the COVID-19 epidemic. For detecting infections, we are using new diagnostic techniques more than ever before.”
Increased levels of antibiotic-resistant bacteria
Despite these measures, the hospital, like many others in the European Region, has had to deal with increased levels of antibiotic-resistant bacteria during the pandemic.
“There have been several bacterial infections due to Pseudomonas and Enterococci, often with high levels of resistance. I believe that widespread use of third-generation cephalosporins can lead to an increase in resistance, especially in a hospital setting.”
Underlining the need for careful evaluation, Dr Soldani feels that more investigation is required to assess the impact of COVID-19 on antibiotic use in hospital settings. The situation is complex as some aspects of the pandemic in hospitals actually appeared to reduce antibiotic use. As the range of activities in the hospital was scaled back and only focused on emergencies, there were fewer health care-associated infections, which are often resistant to antibiotics.
“With the experience that we have gained, I believe that we would now adopt a different approach if we found ourselves in a similar situation once again. The use of antibiotics would most likely be more restricted. I think that once COVID-19 is laboratory-confirmed, which takes much less time than before, if there are no signs of bacterial superinfection, then using antibiotics should be avoided.”