COVID-19 and the potential long-term impact on antimicrobial resistance

Antibiotics with Antiviral and Anti-Inflammatory Potential Against Covid-19: A Review

In Covid-19 cases, elderly patients in long-term care facilities, children younger than five years with moderate symptoms, and patients admitted to ICU or with comorbidities are at a high risk of coinfection, as suggested by the evidence. Thus, in these patients, antibiotic therapy based on empirical evidence is necessary. Finding appropriate antimicrobial agents, especially with antiviral and anti-inflammatory properties, is a promising approach to target the virus and its complications, hyper-inflammation, and microorganisms resulting in co-infection. Moreover, indiscriminate use of antibiotics can be accompanied by Clostridioides difficile colitis, the emergence of resistant microorganisms, and adverse drug reactions, particularly kidney damage and QT prolongation. Therefore, rational administration of efficient antibiotics is an important issue. The main objective of the present review is to provide a summary of antibiotics with possible antiviral activity against SARS-CoV-2 and anti-immunomodulatory effects to guide scientists for further research. Besides, the findings can help health professionals in the rational prescription of antibiotics in Covid-19 patients with a high risk of co-infection.

Evaluation of changes in antimicrobial susceptibility in bacteria infecting children and their mothers in pediatric, neonatal-intensive care unit, and gynecology/obstetrics wards of a quaternary referral hospital during the COVID-19 pandemic

The World Health Organization released a statement warning of increased risk for the incidence of multidrug resistant microorganisms and the absence of new drugs to control such infections soon. Since the beginning of the COVID-19 pandemic, the prescription of antimicrobial agents has increased and may have accelerated the emergence of multidrug resistant (MDR) bacteria. This study aimed to evaluate maternal and pediatric infections within a hospital from January 2019 to December 2021. An observational retrospective cohort study was performed at a quaternary referral hospital in a metropolitan area of Niteroi city, Rio de Janeiro state, Brazil. A total of 196 patients' medical records were analyzed. The data from 90 (45.9%) patients were collected before the SARS-CoV-2 pandemic, 29 (14.8%) from the 2020 pandemic period, and 77 (39.3%) from the 2021 pandemic period. A total of 256 microorganisms were identified during this period. Out of those, 101 (39.5%) were isolated in 2019, 51 (19.9%) in 2020, and 104 (40.6%) in 2021. Antimicrobial susceptibility tests were performed on 196 (76.6%) clinical isolates. The exact binomial test showed that the distribution of Gram-negative bacteria was predominant. The most common microorganism was Escherichia coli (23%; n = 45), followed by Staphylococcus aureus (17.9%, n = 35), Klebsiella pneumoniae (12.8%, n = 25), Enterococcus faecalis (7.7%, n = 15), Staphylococcus epidermidis (6.6%, n = 13) and Pseudomonas aeruginosa (5.6%, n = 11). Staphylococcus aureus was the predominant species among resistant bacteria. Among the antimicrobial agents tested, the following were resistant, presented on a descending scale: penicillin (72.7%, p = 0.001, Binomial test), oxacillin (68.3%, p = 0.006, Binomial test), ampicillin (64.3%, p = 0.003, Binomial test), and ampicillin/sulbactam (54.9%, p = 0.57, Binomial test). Infections with S. aureus were 3.1 times greater in pediatrics and maternal units than in other hospital wards. Despite the global reduction in the incidence of MRSA, we observed an increase in MDR S. aureus in this study. No changes were observed in the frequency of resistance profiles of the clinical isolates after the establishment of the global SARS-CoV-2 pandemic. More comprehensive studies are needed to understand the impact of the global SARS-CoV-2 pandemic on the resistance levels of bacteria associated with neonate and pediatric patients.

Management of Acute Cystitis in the Era of COVID-19

Purpose of Review

No specific guidelines have been developed for acute cystitis management during the COVID-19 pandemic. This review aims to provide up-to-date information about treatment and follow-up in patients with symptoms suggesting lower urinary tract infection.

Recent Findings

Uncomplicated cystitis does not need microbiological confirmation; thus, clinical diagnosis via telephone interview or questionnaires may be done. When complicated infections are suspected, in-person evaluation or close follow-up is mandatory. Antibiotic treatment is still the gold standard for treatment, although non-pharmacological strategies have also been suggested and further investigations are warranted.

Summary

Urinary tract infections are still a frequent reason for consultation that needs to be addressed in both primary care and specialized levels. Their management during the pandemic is similar than in precedent years, but telehealth options have emerged which can facilitate diagnosis and treatment.

Pattern of antibiotic use and bacterial co-infection in hospitalized Covid-19 patients

Background

There is evidence that bacterial co-infection in respiratory viruses leads to morbidity and mortality. Patients with decreased immunity are prone to bacterial co-infection. A lack of judicious use of antibiotics leads to the spread of multi-drug resistant bacteria (MDR) that have a long-term negative impact. In this study, we attempted to observe the pattern of antibacterial use and its impact on secondary bacterial infection.

Methods

An observational study was conducted at Alexandria Main University Hospital (AMUH) (Alexandria University) from June 2021- February 2022. Study participants were admitted to the Intensive Care Unit (ICU) with confirmed Covid-19 (by Polymerase Chain Reaction (PCR) and Computed tomography (CT) scan). The following data was collected (Demographic, clinical, and laboratory data).In this study, the Pattern of antibiotic use as well as the occurrence of secondary bacterial infections were reported.

Results

Among 121 patients included in the present study, all received antibiotics empirically. Upon admission (19.8%) showed urinary tract infection, (11.5%) had bloodstream infection, and (57.7%) had respiratory tract infection. After 10 days secondary bacterial infection occurred in 38 patients (61.2%) with (24.1%) Urinary tract infection (UTI), (12.9%) Bloodstream infection (BSI), and (72.2%) respiratory tract infection. The respiratory sample size was (45) patients due to Infection Control (IC) restrictions on the aerosol-producing procedure.

Conclusion

Upon admission, all patients received broad-spectrum antibiotics while the incidence of bacterial co-infection was low.

NDM-producing Enterobacterales prevalence associated to COVID-19 in a tertiary hospital

Colonizations/Infections caused by carbapenem-resistant Enterobacterales are of great clinical and epidemiological importance due to their rapid dissemination and high mortality rates. In this scenario, the use of antibiotics intensified by the COVID-19 pandemic has brought about a great warning on the real impact that this pandemic could have on antimicrobial management programs and long-term antimicrobial resistance rates. The objective of this study was to evaluate the increase of New Delhi Metallo β-Lactamase (NDM)-producing Enterobacterales cases in COVID-19 units of a complex Brazilian tertiary hospital. This retrospective observational study included all patients admitted to the hospital identified as colonized or infected by NDM-producing Gram negative bacilli (GNB), from January 2017 to April 2021. Forty-two NDM-producing Enterobacterales were identified in 39 patients. The rate of NDM cases per total surveillance cultures increased progressively between 2017 and 2021 (chi-2 for trend, p < 0.0001) and was associated with a higher occurrence specifically in COVID units (Fisher exact, p < 0.0001). The molecular investigation of the NDM-producing Klebsiella pneumoniae strains revealed the emergence of diverse clones during the COVID-19 period, also with possible evidence of horizontal transmission among patients within COVID units. NDM-producing Enterobacterales with multiple and different clonalities in the COVID-19 units also raised questions about the importance of other factors besides horizontal clonal transfer, including the increase of antimicrobial consumption by these patients.

Alternatives Therapeutic Approaches to Conventional Antibiotics: Advantages, Limitations and Potential Application in Medicine

Resistance to antimicrobials and particularly multidrug resistance is one of the greatest challenges in the health system nowadays. The continual increase in the rates of antimicrobial resistance worldwide boosted by the ongoing COVID-19 pandemic poses a major public health threat. Different approaches have been employed to minimize the effect of resistance and control this threat, but the question still lingers as to their safety and efficiency. In this context, new anti-infectious approaches against multidrug resistance are being examined. Use of new antibiotics and their combination with new β-lactamase inhibitors, phage therapy, antimicrobial peptides, nanoparticles, and antisense antimicrobial therapeutics are considered as one such promising approach for overcoming bacterial resistance. In this review, we provide insights into these emerging alternative therapies that are currently being evaluated and which may be developed in the future to break the progression of antimicrobial resistance. We focus on their advantages and limitations and potential application in medicine. We further highlight the importance of the combination therapy approach, wherein two or more therapies are used in combination in order to more effectively combat infectious disease and increasing access to quality healthcare. These advances could give an alternate solution to overcome antimicrobial drug resistance. We eventually hope to provide useful information for clinicians who are seeking solutions to the problems caused by antimicrobial resistance.

Antibiotics Usage and Resistance among Patients with Severe Acute Respiratory Syndrome Coronavirus 2 in the Intensive Care Unit in Makkah, Saudi Arabia

Antibiotic resistance is a global health and development threat, especially during the Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) pandemic. Therefore, the current study was conducted to describe antibiotic usage and resistance among patients with COVID-19 in the intensive care unit (ICU) in Makkah, Saudi Arabia. In this cross-sectional study, only patients with positive COVID-19 status (42 patients) admitted to the ICU at the King Faisal Hospital were selected using a census sampling method. The susceptibility test of bacteria was carried out according to the standard protocol. The identified strains were tested in-vitro against several antibiotics drugs. Statistical analysis was performed using SPSS version 24. A total of 42 patients were included, with a mean age of 59.35 ± 18 years. Of them, 38.1% were males, and 61.9% were females. 35.7% have blood group O +. For age and blood groups, statistically significant associations were found between males and females, with p-values = 0.037 and 0.031, respectively. A large percentage (42.7%) of the obtained samples contained Klebsiella Pneumoniae; all bacteria were multidrug-resistance bacteria. Furthermore, 76.2% of bacteria were resistant to Ampicillin, 66.7% were resistant to Ciprofloxacin, 64.3% were resistant to Levofloxacin, 57.1% were resistant to Imipenem, and 57.1% were resistant to Moxifloxacin. On the contrary, among the 40 examined antibiotics, the effective antibiotics were Daptomycin, Linezolid, Mupirocin, Synercid, Teicoplanin, Vancomycin, and Nitrofurantoin. Our study demonstrates that antibiotic resistance is highly prevalent among ICU patients with COVID-19 at the King Faisal Hospital. Additionally, all bacteria were multidrug-resistance bacteria. Therefore, this high prevalence should be seriously discussed and urgently considered.

Bacteriophage Cocktails in the Post-COVID Rehabilitation

Increasing evidence suggests that gut dysbiosis is associated with coronavirus disease 2019 (COVID-19) infection and may persist long after disease resolution. The excessive use of antimicrobials in patients with COVID-19 can lead to additional destruction of the microbiota, as well as to the growth and spread of antimicrobial resistance. The problem of bacterial resistance to antibiotics encourages the search for alternative methods of limiting bacterial growth and restoring the normal balance of the microbiota in the human body. Bacteriophages are promising candidates as potential regulators of the microbiota. In the present study, two complex phage cocktails targeting multiple bacterial species were used in the rehabilitation of thirty patients after COVID-19, and the effectiveness of the bacteriophages against the clinical strain of Klebsiella pneumoniae was evaluated for the first time using real-time visualization on a 3D Cell Explorer microscope. Application of phage cocktails for two weeks showed safety and the absence of adverse effects. An almost threefold statistically significant decrease in the anaerobic imbalance ratio, together with an erythrocyte sedimentation rate (ESR), was detected. This work will serve as a starting point for a broader and more detailed study of the use of phages and their effects on the microbiome.

Onchocerciasis: Current knowledge and future goals

Human Onchocerciasis, caused by infection by the filarial nematode Onchocerca volvulus, is a neglected public health disease that affects millions of people in the endemic regions of sub-Saharan Africa and Latin America. It is also called river blindness because the Blackflies that transmit infection breeds in rapidly flowing fresh water streams and rivers. This review features state-of-the-art data on the parasite, its endobacteria Wolbachia, the prevalence of the infection and its geographical distribution, its diagnostics, the interaction between the parasite and its host, and the pathology of Onchocerciasis. By development and optimization of the control measures, transmission by the vector has been interrupted in foci of countries in the Americas (Colombia, Ecuador, Mexico, and Guatemala)and inSudan, followed by Onchocerciasis eliminations. The current state and future perspectives for vector control and elimination strategy are described.

COVID-19 Mixed Impact on Hospital Antimicrobial Stewardship Activities: A Qualitative Study in UK-Based Hospitals

Antimicrobial resistance (AMR) is a well-known global threat due to the subsequent increase in antimicrobial usage. Several antimicrobial stewardship (AMS) strategies have been implemented to curb irrational prescribing and reduce the AMR burden. However, since the beginning of the COVID-19 pandemic, it has enormously impacted the healthcare system and jeopardized public health, causing millions of deaths globally. Our semi-structured qualitative study aimed to explore the impact of COVID-19 on AMS activities in the UK hospitals. Seventeen interviews were conducted with health care professionals who were part of AMS teams (consultant medical microbiologists, infectious disease consultants, antimicrobial pharmacists). Interviews were audio-recorded and transcribed. An inductive thematic framework was adopted to analyse and create the themes. After agreement of the hierarchical framework definition, all transcripts were coded accordingly. Four main themes and 15 sub-themes were identified. These main themes were: (1) AMS activities or strategies before and during the pandemic; (2) challenges to implementing AMS activities before and during the pandemic; (3) information from public authorities on AMS during the pandemic; and (4) new AMS activities/strategies adopted during the pandemic. Staff vacancies, redeploying of AMS staff to other duties and meeting the burden related to the COVID-19 and lack of resources were the most frequently identified contributing factors to withheld AMS activities during the pandemic. However, modifications to the hybrid working environment, i.e., remote or flexible working, allowed for resumption of AMS activities including virtual ward rounds, virtual meetings and other activities. Further research needs to assess the impact of the hybrid delivery system on AMS activities.

A step forward in antibiotic use and resistance monitoring: a quarterly surveillance system pilot in 11 European Union/European Economic Area countries, September 2017 to May 2020

BackgroundSurveillance of antimicrobial resistance (AMR) and antimicrobial use (AMU) in Europe is currently annual.AimTo study the feasibility and scalability of a quarterly AMR/AMU surveillance system in the European Union/European Economic Area (EU/EEA).MethodsWe conducted a longitudinal study within the scope of the EU-JAMRAI project. Seventeen partners from 11 EU/EEA countries prospectively collected 41 AMU and AMR indicators quarterly from September 2017 to May 2020 for the hospital sector (HS) and primary care (PC). Descriptive statistics and coefficients of variation (CV) analysis were performed.ResultsData from 8 million hospital stays and 45 million inhabitants per quarter were collected at national (n = 4), regional (n = 6) and local (n = 7) levels. Of all partners, five were able to provide data within 3 months after each preceding quarter, and eight within 3-6 months. A high variability in AMU was found between partners. Colistin was the antibiotic that showed the highest CV in HS (1.40; p < 0.0001). Extended-spectrum beta-lactamase-producing Escherichia coli presented the highest incidence in HS (0.568 ± 0.045 cases/1,000 bed-days per quarter), whereas ciprofloxacin-resistant E. coli showed the highest incidence in PC (0.448 ± 0.027 cases/1,000 inhabitants per quarter). Barriers and needs for implementation were identified.ConclusionThis pilot study could be a first step towards the development of a quarterly surveillance system for AMU and AMR in both HS and PC in the EU/EEA. However, committed institutional support, dedicated human resources, coordination of data sources, homogeneous indicators and modern integrated IT systems are needed first to implement a sustainable quarterly surveillance system.

The Prevalence of Bacterial and Fungal Coinfections among Critically Ill COVID-19 Patients in the ICU in Jordan

BACKGROUND

Secondary bacterial and fungal coinfections have been reported among critically ill coronavirus disease-19 (COVID-19) patients and are associated with increased disease severity and mortality incidence (MI) rates.

AIMS

This study aimed to track bacterial and fungal coinfections among COVID-19 patients in the intensive care unit (ICU) and to assess the impact of these infections on disease prognosis and patient outcomes in Jordan.

MATERIALS AND METHODS

This was a single-center study that enrolled 46 ICU patients diagnosed with COVID-19. Microbiological and antimicrobial susceptibility results and inflammatory biomarker data were retrospectively analyzed.

RESULTS

The MI rate attributed to bacterial and fungal coinfections was 84.8%, and the highest rate was reported among patients older than 70 years (66.7%). The MI rate related to bacterial coinfections was 95.2%, whereas that of fungal coinfections was 4.8%. The most commonly isolated bacterium in the blood was a coagulase-negative staphylococcus (41%), followed by Klebsiella pneumoniae in nasopharyngeal swabs (34%) and Acinetobacter baumannii in sputum samples (31%). Candida species were the sole cause of fungal coinfections in the studied population. In particular, Candida albicans was isolated from 3% of patients with bacteremia, whereas Candida glabrata was isolated from 8% of nasopharyngeal swabs. Klebsiella pneumoniae was considered the major cause of upper respiratory tract infections (34%). Multifactorial infection was significantly associated with increased MI (p value <0.001).

CONCLUSION

COVID-19 MI is associated with respiratory bacterial/fungal coinfections. The ability to predict bacterial and fungal coinfections in ICU patients may be crucial to their survival and prognosis.

Antimicrobial Stewardship during COVID-19 Outbreak: A Retrospective Analysis of Antibiotic Prescriptions in the ICU across COVID-19 Waves

The demographics and outcomes of ICU patients admitted for a COVID-19 infection have been characterized in extensive reports, but little is known about antimicrobial stewardship for these patients. We designed this retrospective, observational study to investigate our hypothesis that the COVID-19 pandemic has disrupted antimicrobial stewardship practices and likely affected the rate of antibiotic de-escalation (ADE), patient outcomes, infection recurrence, and multidrug-resistant bacteria acquisition. We reviewed the prescription of antibiotics in three ICUs during the pandemic from March 2020 to December 2021. All COVID-19 patients with suspected or proven bacterial superinfections who received antibiotic treatment were included. The primary outcome was the rate of ADE, and secondary outcomes included the rate of appropriate empirical treatment, mortality rates and a comparison with a control group of infected patients before the COVID-19 pandemic. We included 170 COVID-19 patients who received antibiotic treatment for a suspected or proven superinfection, of whom 141 received an empirical treatment. For the latter, antibiotic treatment was de-escalated in 47 (33.3%) patients, escalated in 5 (3.5%) patients, and continued in 89 (63.1%) patients. The empirical antibiotic treatment was appropriate for 87.2% of cases. ICU, hospital, and day 28 and day 90 mortality rates were not associated with the antibiotic treatment strategy. The ADE rate was 52.2% in the control group and 27.6% in the COVID-19 group (p < 0.001). Our data suggest that empirical antibiotic treatment was appropriate in most cases. The ADE rates were lower in the COVID-19 group than in the control group, suggesting that the stress associated with COVID-19 affected our practices.

Profile of Co-Infection Prevalence and Antibiotics Use among COVID-19 Patients

Bacterial co-infection in COVID-19 patients significantly contributes to the worsening of the prognosis based on morbidity and mortality. Information on the co-infection profile in such patients could help to optimize treatment. The purpose of this study was to describe bacterial co-infections associated with microbiological, clinical, and laboratory data to reduce or avoid a secondary infection. A retrospective cohort study was conducted at Sant'Anna and San Sebastiano Hospital from January 2020 to December 2021. Bacterial co-infection was detected in 14.3% of the COVID-19-positive patients. The laboratory findings on admission showed significant alterations in the median D-dimer, C-reactive protein, interleukin-6, and lactate dehydrogenase values compared to normal values. All inflammatory markers were significantly elevated. The most common pathogens isolated from blood cultures were E. faecalis and S. aureus. Instead, the high prevalence of respiratory tract infections in the COVID-19 patients was caused by P. aeruginosa (41%). In our study, 220 (82.4%) of the COVID-19 patients received antimicrobial treatment. Aminoglycosides and β-lactams/β-lactamase inhibitors showed the highest resistance rates. Our results showed that older age, underlying conditions, and abnormal laboratory parameters can be risk factors for co-infection in COVID-19 patients. The antibiotic susceptibility profile of bacterial pathogen infection provides evidence on the importance, for the clinicians, to rationalize and individualize antibiotic usage.

Clinical Presentations, Predictive Factors, and Outcomes of Clostridioides difficile Infection among COVID-19 Hospitalized Patients—A Single Center Experience from the COVID Hospital of the University Clinical Center of Vojvodina, Serbia

Background: This study aimed to investigate the clinical form, risk factors, and outcomes of patients with COVID-19 and Clostridioides difficile co-infections. Methods: This retrospective study (2 September 2021-1 April 2022) included all patients with Clostridioides difficile infection (CDI) and COVID-19 infection who were admitted to the Covid Hospital of the University Clinical Center of Vojvodina. Results: A total of 5124 COVID-19 patients were admitted to the Covid Hospital, and 326 of them (6.36%) developed hospital-onset CDI. Of those, 326 of the CDI patients (88.65%) were older than 65 years. The median time of CDI onset was 12.88 days. Previous hospitalizations showed 69.93% of CDI patients compared to 38.81% in the non-CDI group (p = 0.029). The concomitant antibiotics exposure was higher among the CDI group versus the non-CDI group (88.65% vs. 68.42%, p = 0.037). Albumin levels were ≤ 25 g/L among 39.57% of the CDI patients and 21.71% in the non-CDI patients (p = 0.021). The clinical manifestations of CDI ranged from mild diarrhea (26.9%) to severe diarrhea (63.49%) and a complicated form of colitis (9.81%). Regarding outcomes, 79.14% of the CDI patients recovered and 20.86% had fatal outcomes in-hospital. Although a minority of the patients were in the non-CDI group, the difference in mortality rate between the CDI and non-CDI group was not statistically significant (20.86% vs. 15.13%, p = 0.097). Conclusions: Elderly patients on concomitant antibiotic treatments with hypoalbuminemia and with previous healthcare exposures were the most affected by COVID-19 and CD co-infections.

Antibiotic Use among Patients Hospitalized with COVID-19 and Treated in Three Different Clinics

Objective

In this study, we aimed to determine and compare the rates of empirical antibiotic use and duration between the chest diseases clinic (CDC), infectious disease clinic (IDC), and internal medicine clinic (IMC) among patients hospitalized because of COVID-19.

Methods

This cross-sectional study was performed in a single university hospital. The study included all patients aged 18 years and older hospitalized with a PCR-confirmed COVID-19 between May 30, 2021, and August 30, 2021. Clinical and laboratory findings were recorded from the electronic medical records database.

Results

The study included a total of 581 inpatients, of whom 310 (53.4%) were women. Of the 581 patients, 475 (81.8%) were prescribed antibiotics. The rate of antibiotic prescription was 71.6% for IDC, 88.5% for CDC, and 87.4% for IMC. The most commonly used antibiotic was moxifloxacin in all groups. The mean treatment duration was 8.9±6.16 days. The mean duration of antibiotic treatment was 11.1±5.90 days for CDC, 11.3±6.74 days for IMC, and 5.3 days±3.76 for IDC.

Conclusion

Patients with COVID-19 who were treated in IDC had a lower rate and shorter duration of antibiotic use compared to the other clinics. However, the rate of antibiotic prescription in all three groups was very high. Therefore, antimicrobial management programs should be meticulously conducted to reduce unnecessary antibiotic use.

ESKAPE bacteria characterization reveals the presence of Acinetobacter baumannii and Pseudomonas aeruginosa outbreaks in COVID-19/VAP patients

INTRODUCTION

A reduction of detection of outbreaks by multidrug-resistant bacteria in critical areas has been reduced due to COVID-19 pandemic. Therefore, molecular epidemiological surveillance should be a primary tool to reveal associations not evident by classical epidemiology. The aim of this work was to demonstrate the presence of hidden outbreaks in the first wave of the COVID-19 pandemic and to associate their possible origin.

METHODS

A population of 96 COVID-19 patients was included in the study (April to June 2020) from Hospital Juárez de México. Genetic identification and antimicrobial susceptibility testing of VAP causative agents isolated from COVID-19 patients was performed. Resistance phenotypes were confirmed by PCR. Clonal association of isolates was performed by analysis of intergenic regions obtained. Finally, the association of clonal cases of VAP patients was performed by timelines.

RESULTS

ESKAPE and non-ESKAPE bacteria were identified as causative agents of VAP. ESKAPE bacteria were classified as MDR and XDR. Only A. baumannii and P. aeruginosa were identified as clonally distributed in 13 COVID-19/VAP patients. Time analysis showed that cross-transmission existed between patients and care areas.

CONCLUSIONS

Acinetobacter baumannii and Pseudomonas aeruginosa were involved in outbreaks non-detected in COVID-19/VAP patients in the first wave of COVID-19 pandemic.

Impact of the COVID-19 on the Health System and Healthcare Workers: A Systematic Review

Context: The coronavirus disease 2019 (COVID-19) pandemic has affected all sectors of life. The health system and healthcare workers also have been affected by the COVID-19 pandemic. Healthcare workers (HCWs) have faced major challenges in working in the hospitals due to COVID-19 pandemic. There is a need to provide evidence regarding challenges to working during the COVID-19 pandemic, specifically in developing countries. Objectives: The objective of this study was to evaluate the effect of the COVID-19 pandemic on health professionals and the health system. Methods: Ten studies conducted from January 1, 2020, to December 31, 2021were included in this review. Common search terms were impact, health, healthcare, providers, abuses, burden, and system. Different databases, such as Scopus, Web of Science, PubMed, and Google Scholar, were used. Data extraction was performed following the PRISMA recommendations. Results: The results of the systematic review showed that the hospitalization rate and numbers of out-patients have increased, leading to imposing a burden on the health system and healthcare workers (HCWs). A serious type of disease may need hospitalization and ventilatory support. The quality of healthcare institutions is unique and complex. HCWs, in their routine activities, face diverse challenges. The unexpected development of the COVID-19 pandemic was a great challenge faced by the health system and health professionals. Conclusions: The pandemic has altered the healthcare system and healthcare practice with innovative workplaces and social challenges confronted by the HCWs.

Antimicrobial Stewardship in the Covid-19 Pandemic

During COVID-19 pandemic, implementing and maintaining an antimicrobial stewardship protocol obtained both low rates of MDR microorganisms and low antimicrobial use in an 800-bed hospital network in northern Italy. Infectious diseases specialist consulting was crucial to maintain this protocol active.

A Time Series Analysis Evaluating Antibiotic Prescription Rates in Long-Term Care during the COVID-19 Pandemic in Alberta and Ontario, Canada

The COVID-19 pandemic affected access to care, and the associated public health measures influenced the transmission of other infectious diseases. The pandemic has dramatically changed antibiotic prescribing in the community. We aimed to determine the impact of the COVID-19 pandemic and the resulting control measures on oral antibiotic prescribing in long-term care facilities (LTCFs) in Alberta and Ontario, Canada using linked administrative data. Antibiotic prescription data were collected for LTCF residents 65 years and older in Alberta and Ontario from 1 January 2017 until 31 December 2020. Weekly prescription rates per 1000 residents, stratified by age, sex, antibiotic class, and selected individual agents, were calculated. Interrupted time series analyses using SARIMA models were performed to test for changes in antibiotic prescription rates after the start of the pandemic (1 March 2020). The average annual cohort size was 18,489 for Alberta and 96,614 for Ontario. A significant decrease in overall weekly prescription rates after the start of the pandemic compared to pre-pandemic was found in Alberta, but not in Ontario. Furthermore, a significant decrease in prescription rates was observed for antibiotics mainly used to treat respiratory tract infections: amoxicillin in both provinces (Alberta: −0.6 per 1000 LTCF residents decrease in weekly prescription rate, p = 0.006; Ontario: −0.8, p < 0.001); and doxycycline (−0.2, p = 0.005) and penicillin (−0.04, p = 0.014) in Ontario. In Ontario, azithromycin was prescribed at a significantly higher rate after the start of the pandemic (0.7 per 1000 LTCF residents increase in weekly prescription rate, p = 0.011). A decrease in prescription rates for antibiotics that are largely used to treat respiratory tract infections is in keeping with the lower observed rates for respiratory infections resulting from pandemic control measures. The results should be considered in the contexts of different LTCF systems and provincial public health responses to the pandemic.

SARS-CoV-2 and Chlamydia pneumoniae co-infection: A review of the literature

Bacterial co-pathogens are commonly identified in viral respiratory infections and are important causes of morbid-mortality. The prevalence of Chlamydia (C.) pneumoniae infection in patients infected with SARS-CoV-2 has not been sufficiently studied. The objective of the present review was to describe the prevalence of C. pneumoniae in patients with coronavirus disease 2019 (COVID-19). A search in MEDLINE and Google Scholar databases for English language literature published between January 2020 and August 2021 was performed. Studies evaluating patients with confirmed COVID-19 and reporting the simultaneous detection of C. pneumoniae were included. Eleven articles were included in the systematic review (5 case cross-sectional studies and 6 retrospective studies). A total of 18 450 patients were included in the eleven studies. The detection of laboratory-confirmed C. pneumoniae infection varied between 1.78 and 71.4% of the total number of co-infections. The median age of patients ranged from 35 to 71 years old and 65% were male. Most of the studies reported one or more pre-existing comorbidities and the majority of the patients presented with fever, cough and dyspnea. Lymphopenia and eosinopenia were described in COVID-19 co-infected patients. The main chest CT scan showed a ground glass density shadow, consolidation and bilateral pneumonia. Most patients received empirical antibiotics. Bacterial co-infection was not associated with increased ICU admission and mortality. Despite frequent prescription of broad-spectrum empirical antimicrobials in patients with coronavirus 2-associated respiratory infections, there is a paucity of data to support the association with respiratory bacterial co-infection. Prospective evidence generation to support the development of an antimicrobial policy and appropriate stewardship interventions specific for the COVID-19 pandemic are urgently required.

Catch-22: War, Refugees, COVID-19, and the Scourge of Antimicrobial Resistance

Wars have hidden repercussions beyond the immediate losses of life, well-being, and prosperity. Those that flee wars and seek refuge in safer locations are not immune to the tragic impacts. Of particular concern is the susceptibility of the refugee populations to infectious diseases and antimicrobial-resistant pathogens. This poses a detrimental risk to these disenfranchised populations, who often have limited access to medical care, sanitation, and nutritious and safe food. Furthermore, antimicrobial-resistant pathogens in refugees can be both transmitted to and acquired from their hosting communities. The latter is particularly problematic when the host countries suffer from serious challenges such as limited resources, pollution, and widespread antimicrobial resistance (AMR). Here, we discuss AMR in refugees of the ongoing Syrian war, a conflict that resulted in the largest population displacement in recent history. We argue that Syrian refugees and their hosting communities are at an elevated risk of complicated and life-threatening AMR infections. We also call on the international community to address this grievous problem that threatens the disenfranchised refugee populations and can spill over across geographic borders to affect multiple countries.

The impact of COVID-19 on essential health service provision for endemic infectious diseases in the South-East Asia region: A systematic review

Background

There is increasing evidence that the COVID-19 pandemic has impacted adversely on the provision of essential health services. The South East Asia region (SEAR) has experienced extremely high rates of COVID-19 infection, and continues to bear a significant proportion of communicable disease burden worldwide.

Methods

We conducted a systematic literature review of quantitative evidence to estimate the impact of COVID-19 on the provision of essential prevention, detection, treatment, and management services for five high-burden infectious diseases across the SEAR.

Findings

A total of 2338 studies were reviewed, and 12 studies were included in our analysis, covering six countries across the SEAR (Bhutan, Sri Lanka, Nepal, Myanmar, Thailand, and India) for three conditions of interest (HIV, TB, dengue fever). We identified significant disruption to TB testing (range=25% to 77.9%) and diagnoses (range=50% to 58%) in India, Nepal, and Indonesia; and similar disruptions were observed for screening, new diagnoses and commencing HIV treatment in India and Thailand. There was also drastically reduced case detection for dengue fever (range=75% to 90% disrupted) in Bhutan and Sri Lanka. No studies were identified for malaria nor hepatitis in any country, and nor for any service in the remaining six SEAR countries.

Interpretation

We identified evidence of significant disruption to the prevention, diagnoses, treatment, and management of TB, HIV, and dengue fever due to the COVID-19 pandemic across multiple SEAR country settings. This has the potential to set back hard-fought gains in infectious disease control across the region. The lack of evidence for the impact of the pandemic on malaria and hepatitis services, and in the remaining six SEAR countries, is an important evidence gap that should be addressed in order to inform future policy for service protection and pandemic preparedness.

Funding

This work was supported by the WHO Sri Lanka Country office.

Descriptive Analysis of Circulating Antimicrobial Resistance Genes in Vancomycin-Resistant Enterococcus (VRE) during the COVID-19 Pandemic

COVID-19 offers ideal premises for bacteria to develop antimicrobial resistance. In this study, we evaluated the presence of several antimicrobial resistance genes (ARG) in vancomycin-resistant Enterococcus (VRE) isolated from rectal swabs from patients at a hospital in Cluj-Napoca, Romania. Rectal swabs were cultivated on CHROMID^® VRE (bioMérieux, Marcy—l’ Étoile, France) and positive isolates were identified using MALDI-TOF Mass Spectrometry (Bruker Daltonics, Bremen, Germany) and further analyzed using the PCR technique for the presence of the following ARGs: van A, van B, tet(M), tet(L), ermB, msrA, mefA, aac(6′)-Im, aph(2)-Ib, ant(4′)-Ia, sul1, sul2, sul3, and NDM1. We isolated and identified 68 isolates of Enterococcus faecium and 11 isolates of Enterococcus faecalis. The molecular analysis showed 66 isolates positive for the vanA gene and eight positive for vanB. The most frequent association of ARG in VRE was vanA-tet(M)-ermB. There was no statistically significant difference between Enterococcus faecium and Enterococcus faecalis regarding ARGs. Our work proves that during the COVID-19 pandemic, highly resistant isolates of Enterococcus were present in patients in the intensive care unit; thus, better healthcare policies should be implemented for the management and control of these highly resistant isolates in the future.

A Comparative Study on Bacterial Co-Infections and Prevalence of Multidrug Resistant Organisms among Patients in COVID and Non-COVID Intensive Care Units

Introduction

Secondary bacterial infections have been reported in majority of patients hospitalized with coronavirus disease 2019 (COVID-19). A study of the antimicrobial susceptibility profiles of these bacterial strains revealed that they were multidrug resistant, demonstrating their resistance to at least three classes of antimicrobial agents including beta-lactams, fluoroquinolones and aminoglycosides. Bacterial co-infection remains as an important cause for high mortality in patients hospitalized with COVID-19.

Methods

In our study, we conducted a retrospective comparative analysis of bacterial co-infections and the antimicrobial resistance profile of bacterial isolates obtained from inpatients admitted in COVID-19 and non-COVID-19 intensive care units. The goal was to obtain the etiology and antimicrobial resistance of these infections for more accurate use of antimicrobials in clinical settings. This study involved a total of 648 samples collected from 356 COVID-19 positive patients and 292 COVID-19 negative patients admitted in the intensive care unit over a period of six months from May to October 2020.

Results

Among the co-infections found, maximum antimicrobial resistance was found in Acinetobacter species followed by Klebsiella species in both the ICU’s. Incidence of bacterial co-infection was found to be higher in COVID-19 intensive care patients and most of these isolates were multidrug resistant strains.

Conclusion

Therefore, it is important that co-infections should not be underestimated and instead be made part of an integrated plan to limit the global burden of morbidity and mortality during the SARS-CoV-2 pandemic and beyond.

Interventional research to tackle antimicrobial resistance in Low Middle Income Countries in the era of the COVID-19 pandemic: lessons in resilience from an international consortium

This article summarizes the consequences of the COVID-19 pandemic, on an international project to tackle antimicrobial resistance (AMR). The research leadership and process, the access to data, and stakeholders were deeply disrupted by the national and international response to the pandemic, including the interruption of healthcare delivery, lockdowns, and quarantines. The key principles to deliver the research through the pandemic were mainly the high degree of interdisciplinary engagement with integrated teams, and equitable partnership across sites with capacity building and leadership training. The level of preexisting collaboration and partnership were also keys to sustaining connections and involvements throughout the pandemic. The pandemic offered opportunities for realigning research priorities. Flexibility in funding timelines and projects inputs are required to accommodate variance introduced by external factors. The current models for research collaboration and funding need to be critically evaluated and redesigned to retain the innovation that was shown to be successful through this pandemic.

A Retrospective Analysis of the Bacterial Infections, Antibiotic Use, and Mortality Predictors of COVID-19 Patients

Purpose

This study aimed to investigate the rate and profile of bacterial infections, mortality-associated predictors, and report the most common microorganisms and antibiotic use in coronavirus disease-19 (COVID-19) patients.

Patients and Methods

This study used a retrospective approach to evaluate the bacterial culture, antibiotic use, comorbidities, imaging, and laboratory discoveries of patients with COVID-19 (hospitalized) confirmed by reverse transcription polymerase chain reaction (RT-PCR) between May and December 2020. We have selected 906 COVID-19 positive patients using a consecutive sampling technique and analyzed data using IBM SPSS-22 statistical software. Statistical analysis included univariate, bivariate, and multivariate analysis. It was carried out using multivariable logistic regression analysis to predict the mortality of COVID-19 patients.

Results

A total of 410 patients, which involved 247 males with a mean age of 53.9 years were evaluated. Based on the results, the positive bacterial culture was detected in 18.3% of all patients who sent the culture sample test, representing bacterial infections. The Acinetobacter baumannii was the most commonly identified organism, while the proportion of patients treated with antibiotics was 83.4%. Furthermore, azithromycin was prescribed in the highest number of patients with approximately 44.3% of all antibiotics. The total mortality rate was 39.8% and its ratio was higher in COVID-19 patients with bacterial infections (65.3%, X² = 25.1, P<0.001). Patients mortality who used antibiotics were also higher compared to those who did not (89% vs 11%, P<0.014). Age, length of hospitalization, bacterial infection, shortness of breath, neutrophil-to-lymphocyte ratio (NLR), and diabetes mellitus were also associated predictors to increased hospital mortality (adjusted OR (aOR) 0.382, P<0.013; aOR 4.265, P<0.001; aOR 3.720, P<0.001; aOR 3.889, P<0.001; aOR 6.839, P<0.003; aOR 1.844, P<0.030), respectively.

Conclusion

This study discovered that there is high use of antibiotics amongst COVID-19 patients; however, the bacterial infection rates did not exceed one-fifth of the total patients. Furthermore, older age, bacterial infections, a longer length of hospitalization, diabetes mellitus, shortness of breath, and higher NLR have a significant impact on the mortality of COVID-19 patients.

Do conspiracy theory and mistrust undermine people's intention to receive the COVID-19 vaccine in Austria?

Conspiracy theories flourish during the coronavirus disease 2019 (COVID-19) pandemic especially regarding vaccinations. As the vaccination reluctancy in Austria is high, it is important to understand the antecedents of vaccination intention at the preapproval stage of the vaccination process. An online survey was conducted in August 2020 in Austria with 217 primarily younger, female, educated participants. A two-step cluster analysis resulted in a sceptics cluster with a clear antivaccination tendency along with a right-wing political position, lower trust in general vaccines and lower education levels and the reference cluster. A considerable percentage of participants reported their reluctancy to have a COVID-19 vaccine. Although vaccination intention can be explained by attitude and subjective norm, this decision-making process is undermined by underlying factors such as conspiracy ideation and political position. Policy makers and health interventionists should take political background into consideration in efforts to increase vaccine compliance.

Low risk of bacterial co-infection, opportunistic diseases, and persistent immunosuppression in people living with HIV and COVID-19

Purpose

SARS-CoV-2 infection produces lymphopenia and CD4+ T-cell decrease, which could lead to a higher risk of bacterial co-infection or impair immunological evolution in people living with HIV (PLWH).

Methods

We investigated the rate of co-infection and superinfection, and the evolution of CD4+ count and CD4+/CD8+ ratio, in hospitalized PLWH with COVID-19.

Results

From March to December 2020, 176 PLWH had symptomatic COVID-19 and 62 required hospitalization (median age, 56 years, 89% males). At admission, 7% and 13% of patients had leukocytosis or increased procalcitonin values and 37 (60%) received empiric antibiotic therapy, but no bacterial co-infection was diagnosed. There were seven cases of superinfection (12%), and one case of P. jiroveci pneumonia during ICU stay. No significant change in CD4+ count or CD4+/CD8+ ratio was observed after discharge.

Conclusion

Bacterial co-infection is not frequent in PLWH with COVID-19. Immune recovery is observed in most of patients after the disease.

The impact of the COVID-19 pandemic on antimicrobial prescribing at a specialist paediatric hospital: an observational study

BACKGROUND

The COVID-19 pandemic has severely impacted healthcare delivery and there are growing concerns that the pandemic will accelerate antimicrobial resistance.

OBJECTIVES

To evaluate the impact of the COVID-19 pandemic on antibiotic prescribing in a tertiary paediatric hospital in London, UK.

METHODS

Data on patient characteristics and antimicrobial administration for inpatients treated between 29 April 2019 and Sunday 28 March 2021 were extracted from the electronic health record (EHR). Interrupted time series analysis was used to evaluate antibiotic days of therapy (DOT) and the proportion of prescribed antibiotics from the WHO 'Access' class.

RESULTS

A total of 23 292 inpatient admissions were included. Prior to the pandemic there were an average 262 admissions per week compared with 212 during the pandemic period. Patient demographics were similar in the two periods but there was a shift in the specialities that patients had been admitted to. During the pandemic, there was a crude increase in antibiotic DOTs, from 801 weekly DOT before the pandemic to 846. The proportion of Access antibiotics decreased from 44% to 42%. However, after controlling for changes in patient characteristics, there was no evidence for the pandemic having an impact on antibiotic prescribing.

CONCLUSIONS

The patient population in a specialist children's hospital was affected by the COVID-19 pandemic, but after adjusting for these changes there was no evidence that antibiotic prescribing was significantly affected by the pandemic. This highlights both the value of routine, high-quality EHR data and importance of appropriate statistical methods that can adjust for underlying changes to populations when evaluating impacts of the pandemic on healthcare.

The Collateral Effects of COVID-19 Pandemic on the Status of Carbapenemase-Producing Pathogens

The serious challenge of antimicrobial resistance continues to threaten public health and lingers in the era of the coronavirus disease 2019 (COVID-19), declared pandemic by the World Health Organization. While the pandemic has triggered the importance of infection control practices and preventive measures such as physical distancing, hand hygiene, travel reduction and quarantine, the ongoing alarm of antimicrobial resistance seems to accompany the pandemic too. Antimicrobial resistance has been fostered during COVID-19, possibly due to high rate of empirical antibiotic utilization in COVID-19 patients, increased use of biocides, and the disruption of proper healthcare for other conditions. Specifically, carbapenemase-producing Gram-negative bacteria have shown to cause secondary bacterial infections in patients hospitalized for COVID-19. Clinical and microbiological evidence of such infections is accumulating in different parts of the world. With the resilient nature of carbapenemases, their association with mortality, and the limited treatment options available, concerns regarding this group of antibiotic-hydrolyzing enzymes during the pandemic are expected to upsurge. While the additional burden carbapenemases exert on healthcare is worrisome, it remains hidden or abandoned among the various health consequences of the pandemic. The purpose of this minireview is to shed a light on carbapenemase-associated infections during such unprecedented time of COVID-19. A focused insight shall be made into carbapenemases, their implications for COVID-19 patients, and the features and consequences of co-infection, with a review of available evidence from pertinent literature. The importance of increased surveillance for carbapenemase-producers and optimizing their management in relation to the pandemic, shall be addressed as well.

Connections between Orthopedic Conditions and Oxidative Stress: Current Perspective and the Possible Relevance of Other Factors, Such as Metabolic Implications, Antibiotic Resistance, and COVID-19

The general opinion in the literature is that these topics remain clearly understudied and underrated, with many unknown aspects and with controversial results in the respective areas of research. Based on the previous experience of our groups regarding such matters investigated separately, here we attempt a short overview upon their links. Thus, we summarize here the current state of knowledge regarding the connections between oxidative stress and: (a) orthopedic conditions; (b) COVID-19. We also present the reciprocal interferences among them. Oxidative stress is, of course, an interesting and continuously growing area, but what exactly is the impact of COVID-19 in orthopedic patients? In the current paper we also approached some theories on how oxidative stress, metabolism involvement, and even antibiotic resistance might be influenced by either orthopedic conditions or COVID-19. These manifestations could be relevant and of great interest in the context of this current global health threat; therefore, we summarize the current knowledge and/or the lack of sufficient evidence to support the interactions between these conditions.

Antibiotic Prescribing in Dutch Daytime and Out-of-Hours General Practice during the COVID-19 Pandemic: A Retrospective Database Study

COVID-19 restrictions have resulted in major changes in healthcare, including the prescribing of antibiotics. We aimed to monitor antibiotic prescribing trends during the COVID-19 pandemic in Dutch general practice, both during daytime and out-of-hours (OOH). Routine care data were used from 379 daytime general practices (DGP) and 28 OOH-services over the period 2019–2021. Per week, we analyzed prescription rates per 100,000 inhabitants, overall, for respiratory and urinary tract infections (RTIs and UTIs) specifically and within age categories. We assessed changes in antibiotic prescribing during different phases of the pandemic using interrupted time series analyses. Both at DGPs and OOH-services significantly fewer antibiotics were prescribed during the COVID-19 pandemic after government measures became effective. Furthermore, the number of contacts decreased in both settings. When restrictions were revoked in 2021 prescription rates increased both at DGP and OOH-services, returning to pre-pandemic levels at OOH-services, but not in DGP. Changes in antibiotic prescribing rates were prominent for RTIs and among children up to 11 years old, but not for UTIs. To conclude, while antibiotic prescribing decreased during the first year of the COVID-19 pandemic both in daytime and out-of-hours, the pandemic does not seem to have a lasting effect on antibiotic prescribing.

It is complicated: Potential short- and long-term impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance—An expert review

As of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has claimed millions of deaths and caused disruptions in health systems around the world. The short- and long-term effects of COVID-19 on antimicrobial resistance (AMR), which was already a global threat before the pandemic, are manifold and complex. In this expert review, we summarize how COVID-19 might be affecting AMR in the short term (by influencing the key determinants antibiotic use, infection control practices and international/local mobility) and which additional factors might play a role in the long term. Whereas reduced outpatient antibiotic use in high-income countries, increased awareness for hand hygiene, and reduced mobility have likely mitigated the emergence and spread of AMR in the short term, factors such as overuse of antibiotics in COVID-19 patients, shortage of personal protective equipment, lack of qualified healthcare staff, and patient overcrowding have presumably facilitated its propagation. Unsurprisingly, international and national AMR surveillance data for 2020 show ambiguous trends. Although disruptions in antibiotic stewardship programs, AMR surveillance and research might promote the spread of AMR, other developments could prove beneficial to the cause in the long term. These factors include the increased public awareness for infectious diseases and infection control issues, the strengthening of the One Health perspective as outlined by the Centers for Disease Control and Prevention, and the unprecedented number of international research collaborations and platforms. These factors could even serve as leverage and provide opportunities to better combat AMR in the future.

Therapeutic Effects of Inhaled Nitric Oxide Therapy in COVID-19 Patients

The global COVID-19 pandemic has become the largest public health challenge of recent years. The incidence of COVID-19-related acute hypoxemic respiratory failure (AHRF) occurs in up to 15% of hospitalized patients. Antiviral drugs currently available to clinicians have little to no effect on mortality, length of in-hospital stay, the need for mechanical ventilation, or long-term effects. Inhaled nitric oxide (iNO) administration is a promising new non-standard approach to directly treat viral burden while enhancing oxygenation. Along with its putative antiviral affect in COVID-19 patients, iNO can reduce inflammatory cell-mediated lung injury by inhibiting neutrophil activation, lowering pulmonary vascular resistance and decreasing edema in the alveolar spaces, collectively enhancing ventilation/perfusion matching. This narrative review article presents recent literature on the iNO therapy use for COVID-19 patients. The authors suggest that early administration of the iNO therapy may be a safe and promising approach for the treatment of COVID-19 patients. The authors also discuss unconventional approaches to treatment, continuous versus intermittent high-dose iNO therapy, timing of initiation of therapy (early versus late), and novel delivery systems. Future laboratory and clinical research is required to define the role of iNO as an adjunct therapy against bacterial, viral, and fungal infections.

Over-the-counter sale of antibiotics during COVID-19 outbreak by community pharmacies in Saudi Arabia: a simulated client study

Background

Recent studies have reflected increased global concern regarding the possible acceleration of bacterial resistance secondary to the reported overuse and misuse of antibiotics during the COVID-19 pandemic. Therefore, this study aimed to investigate the nonprescribed sale of antibiotics by community pharmacies in Saudi Arabia during the COVID-19 outbreak and the pharmacists’ skills in triaging COVID-19 suspects.

Methods

Herein, 120 pharmacies were randomly selected and surveyed by simulated clients who presented gradual demands to convince the encountered pharmacists to agree to the over-the-counter sale of antibiotics. The pharmacists’ responses and counseling skills were documented in addition to their effectiveness in triaging suspected COVID-19 cases.

Results

Nineteen pharmacists (15.8%) were convinced to sell nonprescribed antibiotics after various levels of demand by clients. Moreover, twenty pharmacists (16.7%), who refused to sell nonprescribed antibiotics, referred the clients to clinics where they could easily obtain prescriptions, or to other pharmacies that violate the system. In addition, 29 pharmacists (24.2%) were not concerned about possible COVID-19 suspects, and 47–66 (39.2–55%) of them demonstrated different responses and recommendations. Moreover, 12 pharmacists of the 19 who violated the law did not offer any counseling regarding the use of the antibiotics.

Conclusions

The nonprescribed sale of antibiotics is still prevalent and may have increased during the COVID-19 outbreak in Saudi Arabia, thereby increasing the risk of accelerated bacterial resistance. The pharmacists’ skills in triaging COVID-19 suspects and patient education and counseling were below expectations. Further follow-up studies are highly recommended.

Perception, Attitude, and Confidence of Physicians About Antimicrobial Resistance and Antimicrobial Prescribing Among COVID-19 Patients: A Cross-Sectional Study From Punjab, Pakistan

Background: Patients with coronavirus disease 2019 (COVID-19) could experience multiple coinfections, and judicial antimicrobials, including antibiotics, is paramount to treat these coinfections. This study evaluated physicians' perception, attitude, and confidence about antimicrobial resistance (AMR) and antimicrobial prescribing in patients with COVID-19. Methods: A self-administered and validated online questionnaire comprised of six sections was disseminated among physicians working in public sector hospitals in Punjab, Pakistan, using the convenience sampling method from April to May 2021. The study also assessed the validity and reliability of the study questionnaire using exploratory factor analysis and Cronbach's alpha. In addition, the descriptive and inferential statistics present survey results. Results: A total of 387 physicians participated in this study. The study showed that the questionnaire demonstrated good internal consistency (Cronbach's alpha = 0.77). Most physicians (n = 221, 57.1%) believed that AMR is a considerable problem in Pakistan. Less than a quarter of respondents (n = 91, 23.5%) consulted with local antibiotic resistance data to prescribe antibiotics in COVID-19 patients. However, the respondents were confident to select a suitable antibiotic (n = 229, 59.2%). More than three-quarters of the respondents believed that advice from a senior colleague (n = 336, 86.8%), infectious disease (ID) physician (n = 315, 81.4%), and implementing antimicrobial stewardship programs (ASPs) could facilitate appropriate prescribing of antibiotics in COVID-19 patients. Multivariate logistic regression revealed that physicians with more than 10 years of experience had higher odds of consulting local guidelines for antibiotic therapy (OR, 4.71 95% CI: 1.62-13.73, p = 0.004) than physicians with less than 5 years of experience. Similar trends were found for consulting national guidelines and local resistance data to select an empiric antibiotic therapy. Conclusion: AMR-related awareness was optimal among physicians. Only a few physicians looked up local antibiotic resistance data before prescribing antibiotics to COVID-19 patients empirically. The significant approaches advised by physicians to reduce AMR risk among COVID-19 patients were the implementation of ASPs combined with advice from ID physicians.

The challenge of preventing and containing outbreaks of multidrug-resistant organisms and Candida auris during the coronavirus disease 2019 pandemic: report of a carbapenem-resistant Acinetobacter baumannii outbreak and a systematic review of the literature

BACKGROUND

Despite the adoption of strict infection prevention and control measures, many hospitals have reported outbreaks of multidrug-resistant organisms (MDRO) during the Coronavirus 2019 (COVID-19) pandemic. Following an outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) in our institution, we sought to systematically analyse characteristics of MDRO outbreaks in times of COVID-19, focussing on contributing factors and specific challenges in controlling these outbreaks.

METHODS

We describe results of our own CRAB outbreak investigation and performed a systematic literature review for MDRO (including Candida auris) outbreaks which occurred during the COVID-19 pandemic (between December 2019 and March 2021). Search terms were related to pathogens/resistance mechanisms AND COVID-19. We summarized outbreak characteristics in a narrative synthesis and contrasted contributing factors with implemented control measures.

RESULTS

The CRAB outbreak occurred in our intensive care units between September and December 2020 and comprised 10 patients (thereof seven with COVID-19) within two distinct genetic clusters (both ST2 carrying OXA-23). Both clusters presumably originated from COVID-19 patients transferred from the Balkans. Including our outbreak, we identified 17 reports, mostly caused by Candida auris (n = 6) or CRAB (n = 5), with an overall patient mortality of 35% (68/193). All outbreaks involved intensive care settings. Non-adherence to personal protective equipment (PPE) or hand hygiene (n = 11), PPE shortage (n = 8) and high antibiotic use (n = 8) were most commonly reported as contributing factors, followed by environmental contamination (n = 7), prolonged critical illness (n = 7) and lack of trained HCW (n = 7). Implemented measures mainly focussed on PPE/hand hygiene audits (n = 9), environmental cleaning/disinfection (n = 9) and enhanced patient screening (n = 8). Comparing potentially modifiable risk factors and control measures, we found the largest discrepancies in the areas of PPE shortage (risk factor in 8 studies, addressed in 2 studies) and patient overcrowding (risk factor in 5 studies, addressed in 0 studies).

CONCLUSIONS

Reported MDRO outbreaks during the COVID-19 pandemic were most often caused by CRAB (including our outbreak) and C. auris. Inadequate PPE/hand hygiene adherence, PPE shortage, and high antibiotic use were the most commonly reported potentially modifiable factors contributing to the outbreaks. These findings should be considered for the prevention of MDRO outbreaks during future COVID-19 waves.

Coronavirus disease 2019 (COVID-19): Secondary bacterial infections and the impact on antimicrobial resistance during the COVID-19 pandemic

Secondary bacterial infections and bacterial coinfections are an important complication of coronavirus disease 2019 (COVID-19), leading to antibiotic overuse and increased rates of antimicrobial resistance (AMR) during the COVID-19 pandemic. In this literature review, we summarize the reported rates of secondary bacterial infections and bacterial coinfections in patients with COVID-19, the impact on patient outcomes, the antibiotic treatment approaches employed, and the resistance patterns observed. The reported data suggest that although the incidence of secondary bacterial infections or bacterial coinfections is relatively low, they are associated with worse outcomes such as prolonged hospitalization, intensive care unit admission, mechanical ventilator use, and increased mortality. Interestingly, antibiotic prescription rates are typically higher than secondary bacterial and bacterial coinfection rates, and reports of AMR are common. These findings highlight the need for an improved understanding of secondary bacterial and bacterial coinfection in patients with COVID-19, as well as improved treatment options, to mitigate inappropriate antibiotic prescribing and AMR.

The rise in antimicrobial resistance: An obscure issue in COVID-19 treatment

A saturated health care system with a lack of evidence-based antiviral medicine and ignorance of antimicrobial stewardship during pandemics has prompted clinicians to prescribe a broad-spectrum antibiotic more often. A prospective, cross-sectional study of COVID-infected patients was conducted to gain insight into antibiotic prescribing practices and their impact on antimicrobial resistance. The antibiotic susceptibility test was performed using the disc diffusion method. 318 patients met the study's inclusion criteria, with a mean age of 46 years and 55% (175) of them being males. Antibiotics were prescribed for 93.72% (209) of mild cases, 92.45% (49) of moderate cases, 96.15% (25) of severe cases, and 100% (16) of critical cases of COVID-19. A total of 95 samples were sent in for culture and antibiotic sensitivity testing, with 58.95% (56) confirming growth. The majority of the growth was found to contain E. coli (14). In 54.9% of cases, antibiotics with less than 50% sensitivity to curing bacterial infection were detected. In the study, we found that antibiotics were being used unnecessarily in excessive quantities and that more than half of the antibiotics were less sensitive to isolated bacteria.

Impact of the COVID-19 pandemic on the incidence of multidrug-resistant bacterial infections in an acute care hospital in Brazil

BACKGROUND

The impact of COVID-19 on healthcare- associated infections (HCAI) caused by multidrug-resistant (MDR) bacteria that contribute to higher mortality is a growing area of study METHODS: This retrospective observational study compares the incidence density (ID) of HCAI caused by MDR bacteria (CRE, CRAB, CRP, MRSA and VRE) pre-COVID (2017-2019) and during the COVID-19 pandemic (2020) in overall hospitalized patients and in intensive care (ICU) units.

RESULTS

We identified 8,869 HCAI, of which 2,641 (29.7%) were caused by bacterial MDR, and 1,257 (14.1%) were from ICUs. The overall ID of MDR infections increased 23% (P < .005) during COVID-19. The overall per-pathogen analysis shows significant increases in infections by CRAB and MRSA (+108.1%, p<0.005; +94.7%, p<0.005, respectively), but not in CRE, CRP, or VRE. In the ICU, the overall ID of MDR infections decreased during COVID, but that decline was not significant (-6.5%, P = .26). The ICU per-pathogen analysis of ID of infection showed significant increases in CRAB and MRSA (+42.0%, P = .001; +46.2%, P = .04), significant decreases in CRE and CRP (-26.4%, P = .002; -44.2%, P = 0.003, respectively) and no change in VRE.

CONCLUSIONS

The COVID-19 pandemic correlates to an increase in ID of CRAB and MRSA both in ICU and non-ICU setting, and a decrease in ID of CRE and CRP in the ICU setting. Infection control teams should be aware of possible outbreaks of CRAB and MRSA and promote rigorous adherence to infection control measures as practices change to accommodate changes in healthcare needs during and after the pandemic.

Impact of coronavirus disease 2019 on infectious disease treatment and infection control at a tertiary hospital in Japan

Introduction

Coronavirus disease 2019 (COVID-19) has greatly impacted medical care practices. Although the effects on infectious disease treatment and infection control, such as antimicrobial resistance, have been specified, very few reports exist on the specific effects of COVID-19.

Methods

We investigated the effects of COVID-19 on daily medical practices at a tertiary hospital in Japan by comparing the use of hand sanitizers, the detection of bacteria from blood cultures, and the amount dose of antibacterial drugs used for one year before (April 2019 to March 2020, fiscal year 2019.) and after COVID-19 admissions began (April 2020 to March 2021, fiscal year 2020).

Results

The use of hand sanitizers increased by 1.4–3 times during the year after COVID-19 admissions began; the incidence of methicillin-susceptible Staphylococcus aureus and all S. aureus detected in blood cultures reduced in all departments. No decrease was observed in the usage of all antibacterial drugs; rather, the usage of all antibacterial drugs tended to increase in all departments. Therefore, no significant change was observed in the detection of drug-resistant bacteria and the trends of antibacterial drug use based on the acceptance of COVID-19 patients.

Conclusions

The prevalence of drug-resistant bacteria and trends of antibacterial drug use remained unchanged despite the increased use of hand sanitizers due to the admission of patients with COVID-19.

Mapping of New Pharmacological Alternatives in the Face of the Emergence of Antibiotic Resistance in COVID-19 Patents Treated for Opportunistic Respiratory Bacterial Pathogens

BACKGROUND

The increase in bacterial resistance against antibiotics is thought to be another type of pandemic after COVID-19. Emergency treatment based on antibiotics is a major influence in increasing this resistance. Bacteria, such as Klebsiella pneumoniae, are the most affected by the indiscriminate use of antibiotics, since they are resistant to most antibiotics currently available on the market.

OBJECTIVE

This review aimed to evaluate patents of new drugs and formulations, for the treatment of infections caused by Klebsiella pneumoniae.

METHODS

The present patent review was carried out through a specialized search database Espacenet. The selection was based on the criteria of patents published from 2010 to May 2021, in any language, and containing the keywords in title or abstract. Also, a research was performed on the PubMed database, using the inclusion criteria.

RESULTS

Twenty-two patents were selected for the analysis according to the aim of the study. The advance of new patents has been mostly observed in the World Intellectual Property Organization, China, and United States. The results showed that the main approach was the drug association, followed by drug carriers, new isolated products, and vaccines.

CONCLUSION

It has been observed that few studies use new drug alternatives for the treatment, probably due to the higher cost of the development and lack of investments. The effectiveness and safety of these therapies depend on the acceptance, the correct prescription, and rational use of medicines. Therefore, this review can further develop new treatments as alternatives against Klebsiella pneumoniae and pneumonia caused by it.

Antibiotics in the Community During the COVID-19 Pandemic: A Qualitative Study to Understand Users' Perspectives of Antibiotic Seeking and Consumption Behaviors in Bangladesh

INTRODUCTION

The COVID-19 pandemic is thought to have led to increased "inappropriate" or "unjustified" seeking and consumption of antibiotics by individuals in the community. However, little reference has been made to antibiotic seeking and using behaviors from the perspectives of users in Bangladesh during this health crisis.

PURPOSE

This study seeks to document how antibiotic medicines are sought and used during a complex health crisis, and, within different contexts, what are the nuanced reasons why patients may utilize these medicines sub-optimally.

METHODS

We used an exploratory, qualitative design. Forty semi-structured telephone interviews were conducted with people diagnosed with COVID-19 (n=20), who had symptoms suggestive of COVID-19 (n=20), and who had received care at home in two cities between May and June 2021 in Bangladesh. In this study, an inductive thematic analysis was performed.

RESULTS

The analysis highlighted the interlinked relationships of antibiotic seeking and consumption behaviors with the diversity of information disseminated during a health crisis. Antibiotic-seeking behaviors are related to previous experience of use, perceived severity of illness, perceived vulnerability, risk of infection, management of an "unknown" illness and anxiety, distrust of expert advice, and intrinsic agency on antimicrobial resistance (AMR). Suboptimal adherence, such as modifying treatment regimes and using medication prescribed for others, were found to be part of care strategies used when proven therapeutics were unavailable to treat COVID-19. Early cessation of therapy was found to be a rational practice to avoid side effects and unknown risks.

CONCLUSION

Based on the results, we highly recommend the take up of a pandemic specific antimicrobial stewardship (AMS) program in the community. To deliver better outcomes of AMS, incorporating users' perspectives could be a critical strategy. Therefore, a co-produced AMS intervention that is appropriate for a specific cultural context is an essential requirement to reduce the overuse of antibiotics during the COVID-19 pandemic and beyond.

Antibiotic prescriptions in the context of suspected bacterial respiratory tract superinfections in the COVID-19 era: a retrospective quantitative analysis of antibiotic consumption and identification of antibiotic prescription drivers

This study aims to quantify antibiotic consumption for suspected respiratory tract superinfections in COVID-19 patients, while investigating the associated drivers of antibiotic prescribing in light of the current signs of antibiotic overuse. Adult patients with a positive COVID-19 diagnosis admitted to a Belgian 721-bed university hospital were analyzed retrospectively (March 11th-May 4th, 2020), excluding short-term admissions (< 24 h). Antibiotic prescriptions were analyzed and quantified, using Defined Daily Doses (DDD) per admission and per 100 bed days. Possible drivers of antibiotic prescribing were identified by means of mixed effects logistic modelling analysis with backwards selection. Of all included admissions (n = 429), 39% (n = 171) were prescribed antibiotics for (presumed) respiratory tract superinfection (3.6 DDD/admission; 31.5 DDD/100 bed days). Consumption of beta-lactamase inhibitor-penicillin combinations was the highest (2.55 DDD/admission; 23.3 DDD/100 bed days). Four drivers were identified: fever on admission (OR 2.97; 95% CI 1.42-6.22), lower SpO₂/FiO₂ ratio on admission (OR 0.96; 95% CI 0.92-0.99), underlying pulmonary disease (OR 3.04; 95% CI 1.12-8.27) and longer hospital stay (OR 1.09; 95% CI 1.03-1.16). We present detailed quantitative antibiotic data for presumed respiratory tract superinfections in hospitalized COVID-19 patients. In addition to knowledge on antibiotic consumption, we hope antimicrobial stewardship programs will be able to use the drivers identified in this study to optimize their interventions in COVID-19 wards.