Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis

Social Media and COVID-19—Perceptions and Public Deceptions of Ivermectin, Colchicine and Hydroxychloroquine: Lessons for Future Pandemics

The capacity for social media to influence the utilization of re-purposed medicines to manage COVID-19, despite limited availability of safety and efficacy data, is a cause for concern within health care systems. This study sought to ascertain links between social media reports and utilization for three re-purposed medicines: hydroxychloroquine (HCQ), ivermectin and colchicine. A combined retrospective analysis of social media posts for these three re-purposed medicines was undertaken, along with utilization and clinical trials data, in South Africa, between January 2020 and June 2021. In total, 77,257 posts were collected across key social media platforms, of which 6884 were relevant. Ivermectin had the highest number of posts (55%) followed by HCQ (44%). The spike in ivermectin use was closely correlated to social media posts. Similarly, regarding chloroquine (as HCQ is not available in South Africa), social media interest was enhanced by local politicians. Sentiment analysis revealed that posts regarding the effectiveness of these repurposed medicines were positive. This was different for colchicine, which contributed only a small number of mentions (1%). Of concern is that the majority of reporters in social media (85%) were unidentifiable. This study provides evidence of social media as a driver of re-purposed medicines. Healthcare professionals have a key role in providing evidence-based advice especially with unidentifiable posts.

The response to COVID-19 among drug retail outlets in Indonesia: A cross-sectional survey of knowledge, attitudes, and practices

Background

Pharmacists have been at the frontline of the COVID-19 response in Indonesia, providing medicines, advice, and referral services often in areas with limited healthcare access. This study aimed to explore their knowledge, attitudes, and practices during the pandemic, so that we can be better prepared for future emergencies.

Methods

A cross-sectional online survey of community pharmacists and pharmacy technicians in Indonesia was conducted between July and August 2020. The dataset was analysed descriptively, and logistic regression was used to explore willingness to participate in COVID-19 interventions.

Findings

4716 respondents participated in the survey. Two-thirds (66·7%) reported knowing only “a little” about COVID-19 and around a quarter (26·6%) said they had not received any COVID-19 guidelines. Almost all were concerned about being infected (97·2%) and regularly took steps to protect themselves and their clients (87·2%). Stock-outs of Personal Protective Equipment (PPE) and other products (32·3%) was the main reason for not taking any precautions. Around a third (37·7%) mentioned having dispensed antibiotics to clients suspected of having COVID-19. To support COVID-19 response efforts, most respondents were willing to provide verbal advice to clients (97·8%), distribute leaflets to clients (97·7%), and participate in surveillance activities (88·8%). Older respondents, those identifying as male, and those working in smaller outlets were more willing to provide information leaflets. Those working in smaller outlets were also more willing to engage in outbreak surveillance.

Interpretation

Drug retail outlets continue to operate at the frontline of disease outbreaks and pandemics around the world. These providers have an important role to play by helping to reduce the burden on facilities and providing advice and treatment. To fulfil this role, drug retail outlets require regular access to accurate guidelines and steady supplies of PPE. Calls for drug retail outlet staff to plat in response efforts including the provision of information to clients and surveillance could ease escalating pressures on the health system during future outbreaks.

Funding

This study was funded by a grant from the Department of Foreign Affairs and Trade, Australia, under the Stronger Health Systems for Health Security Scheme.

Evaluation of Antibacterial and Antiviral Drug Effectiveness in COVID-19 Therapy: A Data-Driven Retrospective Approach

The clinical manifestations associated with COVID-19 disease is mainly due to a dysregulated host response related to the overexpression of inflammatory markers. Until recently, only remdesivir had gained FDA approval for COVID-19 hospitalized patients and there are currently no evidence-based therapeutic options or options for prevention of complications that have been established. Some medical treatments such as antivirals, antibacterials, antithrombotics, antipyretics, corticosteroids, interleukin inhibitors, monoclonal antibodies, convalescent plasma, immunostimulants, and vitamin supplements have been utilized. However, there are limited data to support their effectiveness. Hence, this study was attempted to identify and evaluate the effectiveness of antibacterials and antivirals used for COVID-19 using a retrospective cross-sectional approach based on the medical records of adult patients in four hospitals. The number of antibacterials was calculated in defined daily dose (DDD) per 100 bed-days unit. Both mixed-logit regression and analysis of covariance were used to determine the effectiveness of the aforementioned agents in relation to COVID-19 outcome and patients’ length of stay. The model was weighed accordingly and covariates (e.g., age) were considered in the model. Heart disease was found to be the most common pre-existing condition of COVID-19 hospitalized patients in this study. Azithromycin, an antibacterial in the Watch category list, was used extensively (33–65 DDD per 100 bed-days). Oseltamivir, an antiviral approved by the FDA for influenza was the most prescribed antiviral. In addition, favipiravir was found to be a significant factor in improving patients’ COVID-19 outcomes and decreasing their length of stay. This study strongly suggests that COVID-19 patients’ received polypharmacy for their treatment. However, most of the drugs used did not reach statistical significance in improving the patients’ condition or decreasing the length of stay. Further studies to support drug use are needed.

Azithromycin Misuse During the COVID-19 Pandemic: A Cross-Sectional Study from Jordan

Objective

Since coronavirus disease 2019 (COVID-19) became a global pandemic, repurposing known drugs was the quickest way to combat the disease. The initial screening revealed that azithromycin (AZM) might have potential against COVID-19. Although clinical trials did not prove such efficacy, many countries have put AZM within their guidelines for treating COVID-19. Therefore, the present study was designed to assess the misuse of AZM in Jordan during the COVID-19 pandemic.

Methods and Results

A cross-sectional study was conducted among community pharmacies in Jordan from March 27 to May 8, 2021, and 184 pharmacies data were collected from the Google forms. During COVID-19, 42.9% of pharmacies sold more than 20 packs of prescribed AZM per month compared to 46.7% of pharmacies used to sell 0–5 packs AZM prescriptions per month before the pandemic. During COVID-19, pharmacists significantly dispensed AZM with and without prescriptions 107% and 127%, respectively, more than before the pandemic (p < 0.0001). Overall, pharmacists stocked 121% more AZM packs during COVID-19 than before the pandemic (p < 0.0001). Additionally, most pharmacists (59.7%) believed that AZM could cure COVID-19 patients. However, using multinomial logistic regression analysis, low-experienced pharmacists were unsure if AZM could positively affect COVID-19 patients (p < 0.05, OR = 3.76, 95% CI = 1.23–11.52). Furthermore, low-experienced pharmacists believed that increased use of AZM for the treatment of viral infections could lead to negative consequences (p < 0.001, OR = 0.161, 95% CI 0.063–0.414).

Conclusion

This study demonstrated that AZM is misused by physicians, pharmacists, and the public in Jordan. Since AZM efficacy on SARS-CoV-2 is scarce, there is a need for new guidelines by governmental health authorities to implement strict enforcement of AZM dispensing during COVID-19 to avoid negative consequences of bacterial resistance.

Antimicrobial Resistance in Rivers: A Review of the Genes Detected and New Challenges

River ecosystems are very important parts of the water cycle and an excellent habitat, food, and drinking water source for many organisms, including humans. Antibiotics are emerging contaminants which can enter rivers from various sources. Several antibiotics and their related antibiotic resistance genes (ARGs) have been detected in these ecosystems by various research programs and could constitute a substantial problem. The presence of antibiotics and other resistance cofactors can boost the development of ARGs in the chromosomes or mobile genetic elements of natural bacteria in rivers. The ARGs in environmental bacteria can also be transferred to clinically important pathogens. However, antibiotics and their resistance genes are both not currently monitored by national or international authorities responsible for controlling the quality of water bodies. For example, they are not included in the contaminant list in the European Water Framework Directive or in the US list of Water-Quality Benchmarks for Contaminants. Although ARGs are naturally present in the environment, very few studies have focused on non-impacted rivers to assess the background ARG levels in rivers, which could provide some useful indications for future environmental regulation and legislation. The present study reviews the antibiotics and associated ARGs most commonly measured and detected in rivers, including the primary analysis tools used for their assessment. In addition, other factors that could enhance antibiotic resistance, such as the effects of chemical mixtures, the effects of climate change, and the potential effects of the coronavirus disease 2019 pandemic, are discussed. Environ Toxicol Chem 2022;41:687-714. © 2022 SETAC.

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.

Phage therapy in the Covid-19 era: Advantages over antibiotics

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Excessive use of antibiotics during the COVID-19 pandemic may accelerate the emergence of AMR.

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Antibiotic-mediated dysbiosis significantly impacts immune-homoeostasis and thereby negatively impacting the recovery from COVID-19.

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Antibiotic-induced dysbiosis will also negatively impacts the pulmonary functioning of the COVID-19 patient via the Gut-Lung Axis.

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Bacteriophages or “phage therapy” can be an ideal alternative for antibiotics having desired specificity and availability.

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Phage therapy can also act as an anti-inflammatory agent to avoid cytokine storm in COVID19.

Today, the entire world is battling to contain the spread of COVID-19. Massive efforts are being made to find a therapeutic solution in the shortest possible time. However, the research community is becoming increasingly concerned about taking a shortsighted strategy without contemplating the long-term consequences. For example, It has been reported that only 8.4% of total COVID-19 patients develop a secondary bacterial infection. In comparison, 74.6% of them are administered with antibiotics as prophylactic treatment. We contend that overuse of broad-spectrum antibiotics increases the likelihood of AMR development and negatively affects the patient's recovery due to the prevalence of the "gut-lung axis.". Consequently, the use of antibiotics to treat COVID-19 patients must be rationalized, or an alternative treatment must be sought that does not risk contributing to AMR development and positively impacts the treatment outcomes. Phage therapy, a century-old concept, is one of the most promising approaches that can be adapted to serve this purpose. This review emphasizes the negative impact of excessive antibiotic use in COVID-19 treatment and provides an overview of how phage therapy can be used as an alternative treatment option. We have argued that targeted killing (narrow spectrum) and anti-inflammatory (which can target the primary cause of mortality in COVID-19) properties of phages can be an effective alternative to antibiotics.

Multidrug-Resistant Infections in the Developing World

Antimicrobials are essential in reducing morbidity and mortality from infectious diseases globally. However, due to the lack of effective surveillance measures and widespread overuse, there is an increasing threat to the effectiveness of antimicrobials. Although there is a global increase in antimicrobial resistance, low- and middle-income countries share a much higher burden. Antimicrobial stewardship efforts such as effective surveillance and reduction in overuse can help combat the increase in antimicrobial resistance.

Indiscriminate Use of Antibiotics for COVID-19 Treatment in South Asian Countries is a Threat for Future Pandemics Due to Antibiotic Resistance

The COVID-19 pandemic has put enormous strain on the global public health and healthcare systems. Here we aimed to assess the prevalence and impact of indiscriminate use of antibiotics for COVID-19 treatment in south Asian countries. We observed the indiscriminate use of antibiotics in south Asian countries and other similar parts of the world. Along with vaccines, people in poor and developing countries have been taking antibiotics and some other medications without proper jurisdiction during the waves of the COVID-19 pandemic. We all know that COVID-19 is a viral disease, and only a few patients might have bacterial co-infections. Therefore, the role of antibiotics is ambiguous in most COVID-19 cases. Consequently, the overuse of antibiotics would cause antimicrobial resistance that has the potential to become a 2-edged sword after the COVID-19 pandemic era. Our findings emphasize the judicious use of antibiotics in COVID-19 therapy, especially in poor and developing countries across the globe.

Antimicrobial consumption in patients with COVID-19: a systematic review and meta-analysis

INTRODUCTION

Since the onset of the pandemic, prescribing antimicrobials has become a common practice to treat patients infected with COVID-19.

AREAS COVERED

A systematic literature search was performed in the electronic databases MEDLINE, CINAHL, WHO COVID-19 database, including EMBASE, Scopus, WHO-COVID, LILACS, and Google Scholar to identify original articles published up to 31 July 2021. A random-effects model was used to estimate the pooled prevalence or proportion of antimicrobial consumption among COVID-19 patients.

EXPERT OPINION

We identified 43 original articles, 33 studies from high-income countries, six from upper-middle-income countries, and four from lower-middle-income countries. Most of the studies presented data from hospital or secondary health-care settings (n = 34). Included studies measured antimicrobial consumption as Daily Defined Doses (DDD) or day of therapy (DOT) or percentage. A total of 19 studies measured antimicrobial consumption as DDDs or DOT. Meta-analysis revealed an overall high antimicrobial consumption of 68% (95% CI: 60% to 75%). The subgroup analysis found a lower consumption in high-income countries (58%, 95% CI: 48% to 67%), compared with lower and middle-income countries (89%, 95% CI: 82% to 94%). High antimicrobial consumption found in COVID-19 patients demands implementation of appropriate antimicrobial stewardship interventions.

Mucormycosis in COVID-19 pandemic: Risk factors and linkages

Mucormycosis is a serious and potentially fatal fungal infection caused by a type of rare but opportunistic fungal pathogen called mucormycetes. Recently, mucormycosis, also known as black fungus, made severe chaos in India during the second wave (between April and June 2021) of the tragical COVID-19 epidemic by its sudden and devastating surge with up to 50% mortality rate. While the exact cause of its sharp rise suddenly and specifically during the second wave still remains debatable, it has been noted that the people who are diabetic and have recovered from COVID-19 infection are more predisposed to mucormycosis. Nevertheless, the precise reason and mechanism(s) underlying the surge of this deadly infection needs to be investigated to comprehend its pathogenesis and pathological elements and discover rationale preventative/ therapeutic solutions. It is speculated that the indiscriminate use of steroids, antibiotics and zinc as a self-medication practice that increased during the COVID-19 epidemic may have promoted the dysbiosis of gut microbiota thereby inducing immune-suppression and making the risk group highly susceptible to this mycotic disease. In these contexts, this timely article attempts to contemplate and discuss some of the possible factors and potential mechanisms that can help to understand and explain the conundrum of sudden, steep and deadly upsurge of mucormycosis infections during the second wave of COVID-19 epidemic.

Live Biosensors for Ultrahigh-Throughput Screening of Antimicrobial Activity against Gram-Negative Bacteria

Gram-negative pathogens represent an urgent threat due to their intrinsic and acquired antibiotic resistance. Many recent drug candidates display prominent antimicrobial activity against Gram-positive bacteria being inefficient against Gram-negative pathogens. Ultrahigh-throughput, microfluidics-based screening techniques represent a new paradigm for deep profiling of antibacterial activity and antibiotic discovery. A key stage of this technology is based on single-cell cocultivation of microbiome biodiversity together with reporter fluorescent pathogen in emulsion, followed by the selection of reporter-free droplets using fluorescence-activated cell sorting. Here, a panel of reporter strains of Gram-negative bacteria Escherichia coli was developed to provide live biosensors for precise monitoring of antimicrobial activity. We optimized cell morphology, fluorescent protein, and selected the most efficient promoters for stable, homogeneous, high-level production of green fluorescent protein (GFP) in E. coli. Two alternative strategies based on highly efficient constitutive promoter pJ23119 or T7 promoter leakage enabled sensitive fluorescent detection of bacterial growth and killing. The developed live biosensors were applied for isolating potent E. coli-killing Paenibacillus polymyxa P4 strain by the ultrahigh-throughput screening of soil microbiome. The multi-omics approach revealed antibiotic colistin (polymyxin E) and its biosynthetic gene cluster, mediating antibiotic activity. Live biosensors may be efficiently implemented for antibiotic/probiotic discovery, environmental monitoring, and synthetic biology.

The "Black Fungus" in India: The Emerging Syndemic of COVID-19-Associated Mucormycosis

A surge in cases of mucormycosis is occurring during India's catastrophic “second wave” of the COVID- 19 pandemic. Multiple actions are urgently needed to prevent and treat this life-threatening disease.

Taxonomic and Functional Distribution of Bacterial Communities in Domestic and Hospital Wastewater System: Implications for Public and Environmental Health

The discharge of untreated hospital and domestic wastewater into receiving water bodies is still a prevalent practice in developing countries. Unfortunately, because of an ever-increasing population of people who are perennially under medication, these wastewaters contain residues of antibiotics and other antimicrobials as well as microbial shedding, the direct and indirect effects of which include the dissemination of antibiotic resistance genes and an increase in the evolution of antibiotic-resistant bacteria that pose a threat to public and environmental health. This study assessed the taxonomic and functional profiles of bacterial communities, as well as the antibiotic concentrations in untreated domestic wastewater (DWW) and hospital wastewater (HWW), using high-throughput sequencing analysis and solid-phase extraction coupled to Ultra-high-performance liquid chromatography Mass Spectrometry (UHPLC–MS/MS) analysis, respectively. The physicochemical qualities of both wastewater systems were also determined. The mean concentration of antibiotics and the concentrations of Cl⁻, F⁻ and PO₄³ were higher in HWW samples than in DWW samples. The phylum Firmicutes was dominant in DWW with a sequence coverage of 59.61% while Proteobacteria was dominant in HWW samples with a sequence coverage of 86.32%. At genus level, the genus Exiguobacterium (20.65%) and Roseomonas (67.41%) were predominant in DWW and HWW samples, respectively. Several pathogenic or opportunistic bacterial genera were detected in HWW (Enterococcus, Pseudomonas and Vibrio) and DWW (Clostridium, Klebsiella, Corynebacterium, Bordetella, Staphylocccus and Rhodococcus) samples. Functional prediction analysis indicated the presence of beta-lactam resistance, cationic antimicrobial peptide (CAMP) resistance and vancomycin resistance genes in HWW samples. The presence of these antibiotic resistance genes and cassettes were positively correlated with the presence of pathogens. These findings show the risk posed to public and environmental health by the discharge of untreated domestic and hospital wastewaters into environmental water bodies.

Nasal Microbiota Imbalance as a Contributory Link in the Emergence of COVID-19 Associated Mucormycosis

COVID-19 associated mucormycosis (CAM) is being reported at an elevated frequency and has been declared an ongoing epidemic in India. A huge diabetic population, inappropriate corticosteroid usage and environmental mucoralean spore count, along with COVID-19 associated glycemic imbalance, hypoxemia, increased iron levels, vascular endothelial injury, as well as the immunosuppressive impact are being considered as important risk factors for CAM. The present viewpoint aims to discuss the plausible role of another important facet, the nasal microbiota imbalance, in the emergence of mucormycosis under the prevailing COVID-19 pandemic conditions.

Antimicrobial resistance in low- and middle-income countries: current status and future directions

Introduction: Rising rates of antimicrobial resistance (AMR) globally continue to pose agrave threat to human health. Low- and middle-income countries (LMICs) are disproportionately affected, partly due to the high burden of communicable diseases.Areas covered: We reviewed current trends in AMR in LMICs and examined the forces driving AMR in those regions. The state of interventions being undertaken to curb AMR across the developing world are discussed, and the impact of the current COVID-19 pandemic on those efforts is explored.Expert opinion: The dynamics that drive AMR in LMICs are inseparable from the political, economic, socio-cultural, and environmental forces that shape these nations. The COVID-19 pandemic has further exacerbated underlying factors that increase AMR. Some progress is being made in implementing surveillance measures in LMICs, but implementation of concrete measures to meaningfully impact AMR rates must address the underlying structural issues that generate and promote AMR. This, in turn, will require large infrastructural investments and significant political will.