The Novel Coronavirus COVID-19 Outbreak: Global Implications for Antimicrobial Resistance

Abstract

We are in the midst of the novel coronavirus (COVID-19) pandemic, the most significant global health event since Spanish influenza in the early 20th century. Increasingly draconian measures are being implemented worldwide to try to slow the spread of the virus. Antimicrobial resistance (AMR) has been cited as the most significant threat to the global health and global economy in recent years, but is now likely to be eclipsed by COVID-19 for some time. However, the emergence of COVID-19 also presents some important consequences for the development of AMR. This piece will highlight how managing the COVID-19 crisis could impact AMR in the clinic, beyond the clinic in the community, in the environment and in relation to public awareness. When civilization emerges from the other side of this global health emergency, efforts should be made to understand these potential effects on AMR, the other significant, and constant global health issue of our time. Healthcare systems around the world are under increasingly immense pressure. This is leading to several changes in practice that may have impacts on, or relevance to, AMR. For example, the UK government have published several documents relating to COVID-19 management in clinical settings. In the guidance for primary care, it is recommended that any room that has been used for a patient with a suspected SARS-CoV-2 (the causative agent of COVID-19) infection should remain closed and ventilation switched off until full sterilization has taken place (HM Government, 2020a). With regards to infection prevention and control procedure, additional measures are recommended regarding transmission prevention. These include precautions around direct contact with potentially contaminated surfaces, droplets and aerosols (HM Government, 2020b). These may not become routine management options within clinical settings following the COVID-19 pandemic, however, many of these practices may also reduce dissemination of AMR bacteria at a local and global scale. In particular, extra vigilance around hygiene and additional sterilization procedures may reduce the spread of AMR bacteria. It would be interesting to gather data on the prevalence of AMR infections before and after the outbreak to determine if this is the case. Comparison of whole genome sequences of clinical pathogens before, during and after the pandemic is one potential technique that could elucidate changes in carriage of AMR mechanisms circulating in clinical settings. Databases such as BacWGSTdb (Ruan and Feng, 2016) could also be used to track outbreaks of key AMR pathogens to the species, clonal complex or isolate level. With regards to COVID-19 patients contracting secondary bacterial infections, there are very few data so far. However, 1 to 10% of patients have been reported to contract secondary bacterial infections in two separate studies (Lai et al., 2020). This in comparison to infection with pandemic H1N1, where around 12–19% of hospitalized patients with pneumonia developed secondary bacterial infections (Kim, 2020). Given current data it is not possible to predict whether the cases of secondary bacterial infection following development of COVID-19 will increase or decrease overtime. Clinical microbiologists, as well as radiologists, will be key for making these distinctions (Kim, 2020). However, despite the relatively low confirmation of secondary bacterial infections, there have been comparatively more reports of antibiotic usage when treating COVID-19 patients (Lai et al., 2020), including up to 45% of patients receiving antibiotic treatment (Xu et al., 2020). This is even though the World Health Organization recommended against the use of antibiotics during COVID-19 treatment (Cascella et al., 2020). It has also been suggested that certain antibiotics, such as tecioplanin (a glycopeptide antibiotic) could be used as an antiviral after exhibiting activity against coronaviruses (amongst others) previously (Baron et al., 2020). However, great caution should be used given that inappropriate use or overuse of antibiotics is known to be a significant driver of the emergence of AMR. This is why significant focus on AMR revolves around reducing inappropriate or overuse of antibiotics (NICE, 2018). Countries which have made progress in this area may face less AMR secondary bacterial infections than countries that have experienced limited success in reducing antibiotic consumption. Again, it would be interesting to analyse this data, when available. The second reason use of antibiotics should be considered very carefully is that it may lead the public to assume that all antibiotics are suitable for treatment of viral infections (see “Public Awareness,” below). Outside the clinic, countries are employing measures aimed at reducing transmission of COVID-19 that range from social distancing, to full-on lock down and closing borders. One piece of advice to the public that has remained constant from the beginning, however, is for the public to regularly wash their hands with soap and water (or to use hand sanitiser, when these are unavailable). Use of antimicrobial soaps and disinfectant cleaners by members of the community and in the hospital will have increased hugely over the last few months. Higher usage is likely to continue, and may even remain high following the outbreak due to changes in infection and control policy or individual habits. As discussed above, these increased/improved hygiene practices may reduce the spread of AMR, which is a very positive outcome. However, there is also a potential negative impact that could arise from increased use of such products, as many of them contain biocides. Biocides are antimicrobials found in surface disinfectants and household cleaners (Buffet-Bataillon et al., 2012) that may also lead to the emergence of AMR (Levy, 2002; Maillard, 2005; Pal et al., 2015; Webber et al., 2015). Due to the COVID-19 pandemic, higher concentrations of...