Addressing the challenge of excessive use while at the same time assuring sustainable supply of essential antibiotics is key to making health systems resilient to both COVID-19 and antimicrobial resistance
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This was corrected on march 1, 2020 to clarify that antibiotic susceptibility testing, not Aspartate aminotransferase or equivalents, is a resistance pattern.
The advent of antibiotics significantly increased the chances of surviving serious bacterial infectious diseases. Moreover, antibiotic therapy enabled the development of chemotherapy, organ transplantation, surgery in general and a wide range of medical interventions over the past eight decades. Effective antibiotics are the cornerstone of modern medical practice.
However, in India, poor availability and utilisation of diagnostics, insufficient antibiotic stewardship and compromised infection control both in community and hospital settings result in over-reliance on and over-use of antimicrobials.
Illnesses usually caused by viruses such as diarrhoea and acute upper respiratory infections account for many inappropriate antimicrobial prescriptions in community settings.
With an increased focus on AMR globally and in India, the Indian Council of Medical Research and other stakeholders made important steps to introduce antimicrobial stewardship to rationalise antibiotic prescriptions in hospital settings.
However, according to experts, the novel coronavirus disease (COVID-19) threatens to undermine these efforts. COVID-19 creates conditions that lead to inappropriate use of antibiotics.
Broad-spectrum antibiotic use and overuse is common among COVID-19 patients and prescribing is often based on clinical presentation rather than laboratory markers; besides that, differentiation between bacterial and viral pneumonia can be difficult even with availability of laboratory tests, particularly for severe cases.
The World Health Organization is concerned AMR will be further fuelled by the inappropriate use of antibiotics during the COVID-19 pandemic.
Only a small proportion of COVID-19 patients may need antibiotics to treat subsequent or concomitant bacterial infections and the organisation has issued guidance specifically to not provide antibiotic therapy or prophylaxis to patients with mild COVID-19 or to patients with suspected or confirmed moderate COVID-19 illness unless there is a clinical indication to do so.
The risk of acquiring healthcare-associated infections in the COVID-19 context due to long hospital stay and invasive medical procedures such as invasive ventilation and indwelling catheters expose the importance of keeping antibiotics working for the management of severe COVID-19 cases.
Integrating stewardship into pandemic response
It is therefore important for countries like India to introduce guidelines to define indications and conditions of antibiotic use in COVID-19 patients and encourage treatment providers follow the principles of antimicrobial stewardship.
The development, updating and dissemination of evidence-based guidelines at the country level is urgently needed to support antimicrobial stewardship interventions specific to COVID-19.
In addition, it is crucial to make available diagnostic tests to help in the identification of bacteria and their resistance patterns such as culture / antibiotic susceptibility testing and the diagnostic capacity to differentiate between simple COVID-19 infections from those including co-infections or alternative diagnosis (like imaging, procalcitonin, etc).
In low-resourced systems, laboratory infrastructure is often a challenge. With labs responding swiftly to the pandemic, shifting their limited capacities to COVID-19 and deprioritising cultures / anti-microbial susceptibility testing, not enough cultures are being sent for confirmation for the presence of secondary bacterial or fungal infections in COVID-19 patients.
Concrete measures such as systematic testing of severe COVID-19 patients with suspected bacterial co-infections are needed to better integrate antimicrobial stewardship into the pandemic response.
The increased focus on COVID-19 and the restrictions imposed by the pandemic have affected aspects of the health system response to AMR such as surveillance and training. These aspects have to be preserved and strengthened.
Through proper microbiology diagnostic capacity, it is possible not only to provide better targeted individual patient care but also conduct proper surveillance of antibiotic resistance: Health systems will be able to monitor the threat of antimicrobial resistance that lurks behind the pandemic.
In addition, monitoring of antibiotic consumption is another essential component of proper antibiotic stewardship. Some studies are reporting an increase of up to 75 per cent in antibiotic prescribing.
This is especially true for localised selection pressures in COVID-19 units where antibiotics are being reportedly over-prescribed. This further exposes the need to generate and monitor local trends to inform sound stewardship practices in COVID-19 clinical management while informing the international discussion on reviving the void currently present in the antibiotic innovation pipeline.
Success means achieving sustainable access
Besides the issue of excess, there is an often-overlooked access issue.
As we pointed out a year ago in our article depicting an access issue in ABR, the current pharmaceutical market in India promotes the ‘increases of consumption rates of last-resort antibiotics. The pharmaceutical industry does not see profit in producing relatively inexpensive ‘Access’ group antibiotics, while drugs that guarantee higher pay offs (often from the Watch and Reserve group) are ensured a reliable supply.’
This is however in direct contrast with the WHO General Program of Work 2019-2023 that calls for the proportion of access antibiotics to be more than 60 per cent of overall antibiotic use.
The access crisis in ‘access’ group antibiotics has been further underlined by lack of sustainable suppliers of active pharmaceutical ingredients due to low profit margins over-reliance on imports and certain suppliers.
The Indian drug regulatory authority’s reaction to impose export restrictions on active pharmaceutical ingredients (including antibiotics) during the COVID-19 pandemic to deal with possible shortages at the domestic level could have further threatened continuity of supply.
Managing and mitigating the risks associated with the competition for scarce resources, like essential antibiotics, during a pandemic and beyond requires international cooperation and global solidarity.
Without international mechanisms to achieve sustainable access to novel and existing antibiotics, there remain many challenges for both, low-and middle income countries and high income countries that can be efficiently addressed in a collaborative way.
These include a diversification of manufacturing capacities, improving transparency and forecasting across distribution lines, establishing collaborative pooled procurement mechanisms and initiatives that could be developed among the United Nations, global procurers and other stakeholders to mitigate stockouts and shortages and introducing international platforms with access conditionalities and stewardship measures countries could subscribe to in order to access relevant antibiotics sustainably.
With weaknesses in health systems and public health capacities in many countries, addressing the challenge of excessive use while at the same time assuring sustainable supply of essential antibiotics is key to make health systems resilient to both COVID-19 and antimicrobial resistance.
Dusan Jasovsky is a pharmacist, Jyotsna Singh an advocacy officer and Leena Menghaney a lawyer. They work with the Access Campaign at the international humanitarian medical organisation Médecins Sans Frontières/Doctors Without Borders. Views expressed are the authors’ own and don’t necessarily reflect those of Down To Earth
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