Antimicrobial Awareness Week 2021: Two crucial lessons for AMR on irrational antimicrobial use during COVID-19

Antibiotic misuse was more in strained healthcare systems such as India during COVID-19 than in high-income countries

By Nafis Faizi
Published: Wednesday 24 November 2021

Azithromycin, Doxycycline, Faropenem, Amoxicillin / clavulanic acid, Cefixime. These are five of the many oral antibiotics that were rampantly misused in the novel coronavirus disease (COVID-19). If we add antimicrobials, hydroxychloroquine and ivermectin are the prominent additions.

None of them has been proven to work against COVID-19 per se. Repurposing drugs for use during the pandemic is a worthwhile scientific expedition if there exists some biological plausibility or evidence that it might work.

The WHO focussed on four such therapies, three of which were antivirals — Remdisivir, Lopinavir-Ritonavir and Lopinavir-Ritonavir with Interferon-alpha.

The other drug, an antimalarial — Chloroquine and Hydroxychloroquine were also on the list. All four of them were put under clinical trials for repurposing.

Chloroquine looked very promising. However, Chloroquine had shown such promises in dengue and chikungunya, among other viruses in the past. But the promises never came to fruition in the clinical trials.

Scientists had forewarned that it might be the same in COVID-19. But as none of them were antibiotics, there was no reason to believe that antibiotics would work against this novel virus.

However, such therapeutic misadventures have continued since the first wave of COVID-19 in milder patients and skyrocketed during the deadly and devastating second wave of COVID-19 in India as well as other countries across the world.

Faropenem belongs to the ‘Watch’ group of antibiotics. It is a class indicated to be used only for limited infective symptoms and is more prone to be a target of antibiotic resistance.

COVID-19 is the most disturbing pandemic of our life. But, it has crucial lessons for antibiotic misuse in health systems.

First, the crucial lesson concerning treatment guidelines. Adherence to standard treatment guidelines by healthcare providers is the fundamental pillar of evidence-based medicine.

Therefore, antimicrobial resistance (AMR) policies rightly focus on the stewardship of healthcare providers. However, the standard treatment guidelines (STG) need to be evidence-based, simple, non-ambiguous and locally relevant.

India’s COVID-19 guidelines were slow moving and at times, not evidence-based at all. Ivermectin was prescribed or dispensed by states not only as a treatment but also dispensed to prevent COVID-19.

Such systemic misuse is not a matter of oversight. It reflects the disregard and indifference to processes and principles used in framing standard treatment guidelines.

This has crucial lessons for AMR. While STGs are an essential element of antibiotic policy at all levels of healthcare and need to be regularly updated, irregular updation or implementation could also prove counterproductive.

The feasibility and ease of use should also be an essential element of concern. A very successful example of a regularly updated guideline is eTG (now known as Treatment guidelines) from Australia, which is available on mobile phones and is accessible across all platforms.

India’s expertise in digital health can be harnessed to make an easy-to-use application on antibiotic treatment which is regularly updated with updates from local evidence base. However, it also needs infrastructural support for local evidence generation, especially access to diagnostics.

Second, most antibiotic misuse is due to the absence of access to quality health care. That is why, during COVID-19, the oral antibiotics were more commonly misused, although evidence suggests that injectables such as Piperacillin-Tazobactam were also misused.

Among the higher antibiotics such as ‘Penems,’ the only oral form — ‘Faropenem’ was more commonly misused. Antibiotics were taken during those dire times as a prophylactic and precautionary measure as well as contrary to evidence and rationale.

While this seems like a one-off event, the process is similar to multiple instances of antibiotic misuse during many self-limiting illnesses, in the absence of access or affordability to healthcare.

Such antibiotic misuse in outpatient care is less in health systems with a better access to first point of care. This observation was consistent in COVID-19.

Antibiotic misuse was more in strained healthcare systems such as India, where one study found that “almost everyone who was diagnosed with COVID-19 received an antibiotic in India”, whereas, at the same time, in high-income countries antibiotic use actually declined in 2020.

This also indicates that insurance-based, inpatient-focussed universal health coverage systems, will have little impact on antibiotic misuse. That is unless they are strengthened with a strong primary healthcare, with an improved continuum of care.

In India, prioritising and strengthening the health and wellness centres (HWC) as a first point of care could be essential in achieving this aim. The recently announced ABHIM (Ayushman Bharat Health Infrastructure Mission) in India, which aims to strengthen HWCs, could be a step in the right direction.

In conclusion, lets ponder over what Albert Camus wrote in The Plague, “No longer were there individual destinies; only a collective destiny, made of plague and emotions shared by all.” The imperative of collective destiny is similar for both, the COVID-19 pandemic as well as AMR.

Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth

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