There is no question that antibiotic resistance to deadly bacteria poses a significant public health threat on a national and global scale. There is also no question that COVID-19 has wrought the most serious public health emergency in our lifetime. As these two threats intersect, there are early indications that the COVID-19 pandemic may intensify antibiotic resistance.
Inappropriate antibiotic use has contributed to the growing threat of antibiotic resistance, which renders treatments for common and serious bacterial infections useless, as bacteria develop the ability to defeat the medicine intended to kill them. While antibiotic resistance has been recognized as an increasingly alarming global health threat, the current pipeline of antibiotics in development is dwindling. More investment in research and development is needed to ensure that novel antibiotics are brought to market to meet current and future patient needs. Given a decline in novel antibiotics, it is even more critical to ensure that we are using the life-saving drugs we currently have appropriately.
Although COVID-19 is caused by a virus and antibiotics are not an effective way to treat this illness, antibiotics have been used throughout the pandemic. While there are appropriate uses of antibiotics for underlying secondary bacterial infections in patients with COVID-19, emerging clinical evidence suggests that bacterial co-infection rates for patients with COVID-19 are low but that antibiotic prescribing remains high. A review of coronavirus studies indicates that even though there was only an 8 percent rate of co-infection, over 70 percent of patients were prescribed antibiotics.
During the pandemic, clinical uncertainty around the management and treatment of COVID-19 has contributed to the inappropriate prescription of antibiotics. The disease often presents itself like bacterial pneumonia, and, amid a crisis with patients experiencing serious symptoms, antibiotics were prescribed before clinicians were able to discern whether the patients may have had a bacterial infection. Delays in test results confirming COVID-19 and the presence of a bacterial infection also contribute to inappropriate prescribing. Initially, evidence on possible treatments for COVID-19 was also lacking, and azithromycin (an antibiotic commonly known as ‘Z-Pak’) was being touted as a potential cure. This led to a surge in demand for Z-Pak with at least 10 pharmaceutical companies reporting a shortage of the medication to the U.S. Food and Drug Administration.
Assessing the use of antibiotics during the COVID-19 pandemic is critical to determining its impact on antibiotic resistance patterns. Emerging evidence and treatment guidelines related to COVID-19 will help ensure that health care professionals use antibiotics only when needed. In addition, educating providers, patients, and the general public is critical, especially given the misinformation circulating online and in some news stories about potential treatments for COVID-19, including antibiotics.
In the meantime, antibiotic stewardship programs that currently exist to promote the appropriate use of antibiotics will become even more critical as the threat of antibiotic resistance increases. In 2019, the Centers for Medicare and Medicaid Services finalized a rule requiring all acute care hospitals participating in Medicare or Medicaid to establish antibiotic stewardship programs. This requirement was an important step toward curbing antibiotic resistance, and it is crucial that antibiotic stewardship efforts are reinforced and used routinely. This also applies to the outpatient setting—including primary care practices, dental care practices, urgent care, and others—where antibiotic stewardship programs are equally important.
As UHF has learned in its recent work on antibiotic stewardship programs, evidence-based strategies can be implemented to reduce antibiotic misuse and overuse. The Milstein Toolkit for Ambulatory Care Practices provides tools and templates that outpatient practices can use to assess their antibiotic prescribing as well as an overview of interventions that can be implemented for reducing inappropriate prescribing. The toolkit was developed based on work with over 30 hospital-owned outpatient practices in the New York area to reduce inappropriate prescribing for acute respiratory infections.
COVID-19 has clearly demonstrated the catastrophic consequences of not having treatments readily available to fight a deadly illness. The ultimate consequence of antibiotic resistance is the emergence and spread of antibiotic-resistant pathogens with no effective treatments. Now that the realities of living through a global pandemic are all around us, it’s essential that we remind the health care community and the public of the need to appropriately use antibiotics to prevent future public health crises. We know that antibiotic stewardship programs can help mitigate overuse and misuse of antibiotics and that we need more investment in the development of novel antibiotics.
Next month, we will observe U.S. Antibiotic Awareness Week, an annual event focused on antibiotic resistance. This is an important opportunity to reinforce responsible prescribing and use of antibiotics—especially in light of the COVID-19 pandemic—but we cannot let our attention or efforts stop there. Now more than ever, we must take sustained action to ensure that this longstanding public health threat is not further exacerbated.
Pooja Kothari, RN, MPH, is a senior program manager for United Hospital Fund’s Quality Institute and UHF’s Patricia S. Levinson fellow. The fellowship, established with the generous support of the Robert A. and Patricia S. Levinson Award Fund at the New York Community Trust, aims to advance UHF’s work improving health care for vulnerable populations.
United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from UHF’s Pooja Kothari looks at antibiotic use and prescribing in the era of COVID-19. – UHF President Tony Shih