CON: COVID-19 will not result in increased antimicrobial resistance prevalence

A scoping review of bacterial resistance among inpatients amidst the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic disrupted antimicrobial stewardship and infection prevention operations worldwide, raising concerns for an acceleration of antimicrobial resistance (AMR). Therefore, we aimed to define the scope of peer reviewed research comparing AMR in inpatient bacterial clinical cultures before and after the start of the COVID-19 pandemic.

METHODS

We conducted a scoping review and searched PubMed, Scopus, and Web of Science through 15 June 2023. Our inclusion criteria were: (1) English language, (2) primary evidence, (3) peer-reviewed, (4) clinical culture data from humans, (5) AMR data for at least one bacterial order/species, (6) inpatient setting, (7) use of statistical testing to evaluate AMR data before and during the COVID-19 pandemic. Reviewers extracted country, study design, type of analysis, study period, setting and population, number of positive cultures or isolates, culture type(s), method of AMR analysis, organisms, and AMR results. Study results were organised by organism and antibiotic class or resistance mechanism. AMR results are also summarised by individual study and across all studies.

RESULTS

In total, 4805 articles were identified with 55 papers meeting inclusion criteria. Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus were the most commonly studied organisms. There were 464 bacterial AMR results across all studies with 82 (18%) increase, 71 (15%) decrease, and 311 (67%) no change results.

CONCLUSIONS

The literature examining the impact of COVID-19 on AMR among inpatients is diverse with most results reflecting no change pre/post pandemic. Ongoing inquiry is needed into evolving patterns in AMR post COVID-19.

COVID-19 restrictions limited interactions of people and resulted in lowered E. coli antimicrobial resistance rates

Background

Antibiotic resistance is rising globally and is a major One Health problem. How much person-to-person transmission or 'contagion' contributes to the spread of resistant strains compared with antibiotic usage remains unclear. As part of its COVID-19 response, Australia introduced strict people movement restrictions in early 2020. Along with internal lockdown measures, movement of people into Australia from overseas was severely restricted. These circumstances provided a unique opportunity to examine the association of people movements with changes in resistance rates.

Methods

Monthly resistance data on over 646 000 Escherichia coli urine isolates from 2016 till 2023 were modelled for statistical changes in resistance trends during pre-lockdown, lockdown and post-lockdown periods. Data were available for three clinical contexts (community, hospital and aged-care facilities). Data were also available for antibiotic usage volumes and movements of people into Australia.

Results

In 2020, arrivals into Australia decreased by >95%. Antibiotic community use fell by >20%. There were sharp falls in trend rates of resistance for all antibiotics examined after restrictions were instituted. This fall in trend rates of resistance persisted during restrictions. Notably, trend rates of resistance fell in all three clinical contexts. After removal of restrictions, an upsurge in trend rates of resistance was seen for nearly all antibiotics but with no matching upsurge in antibiotic use.

Conclusions

Restricting the movement of people appeared to have a dramatic effect on resistance rates in E. coli. The resulting reduced person-to-person interactions seems more closely associated with changes in antibiotic resistance than antibiotic usage patterns.

Antimicrobials and antimicrobial resistance genes in the shadow of COVID-19 pandemic: A wastewater-based epidemiology perspective

Higher usage of antimicrobial agents in both healthcare facilities and the communities has resulted in an increased spread of resistant bacteria. However, the improved infection prevention and control practices may also contribute to decreasing antimicrobial resistance (AMR). In the present study, wastewater-based epidemiology (WBE) approach was applied to explore the link between COVID-19 and the community usage of antimicrobials, as well as the prevalence of resistance genes. Longitudinal study has been conducted to monitor the levels of 50 antimicrobial agents (AAs), 24 metabolites, 5 antibiotic resistance genes (ARGs) and class 1 integrons (intI 1) in wastewater influents in 4 towns/cities over two years (April 2020 - March 2022) in the South-West of England (a total of 1,180 samples collected with 87,320 individual AA measurements and 8,148 ARG measurements). Results suggested higher loads of AAs and ARGs in 2021-22 than 2020-21, with beta-lactams, quinolones, macrolides and most ARGs showing statistical differences. In particular, the intI 1 gene (a proxy of environmental ARG pollution) showed a significant increase after the ease of the third national lockdown in England. Positive correlations for all quantifiable parent AAs and metabolites were observed, and consumption vs direct disposal of unused AAs has been identified via WBE. This work can help establish baselines for AMR status in communities, providing community-wide surveillance and evidence for informing public health interventions. Overall, studies focused on AMR from the start of the pandemic to the present, especially in the context of environmental settings, are of great importance to further understand the long-term impact of the pandemic on AMR.

Increase of multidrug-resistant bacteria after the COVID-19 pandemic in a major teaching Hospital in Sicily (2018-2021)

INTRODUCTION

The COVID-19 pandemic has further highlighted the continuing threat of antimicrobial resistance (AMR) to global health and economic development. In the last two decades, AMR has raised increasing concern, with an estimated 4.95 million deaths globally due to bacterial AMR in 2019 alone. The aim of this study was to analyse the impact of the pandemic on the spread of multidrug-resistant organisms (MDROs) using data from the Hospital "P. Giaccone" in Palermo, comparing pre-pandemic and pandemic periods.

METHODS

This observational study involved adult patients who were discharged from the hospital between 01 January 2018 and 31 December 2021. Hospital Discharge Cards were linked with microbiological laboratory reports to assess MDRO isolations. SARS-CoV-2 positivity during hospitalisation was evaluated using the National Institute of Health surveillance system.

RESULTS

A total of 58 427 hospitalisations were evaluated in this study. Half the patients were aged over 65 years (N=26 984) and most admissions were in the medical area (N=31 716). During the hospitalisation period, there were 2681 patients (5%) with MDROs isolations, and 946 patients (2%) were positive for SARS-CoV-2. Multivariable analyses showed that during 2020 and 2021, there was a significantly increased risk of isolation of Staphylococcus aureus, Acinetobacter baumannii, and Klebsiella pneumoniae. Age, weight of the Diagnosis-Related Group (DRG), wards with higher intensity of care, and length-of-stay were associated with a higher risk of MDRO isolation.

CONCLUSION

This study provides new insights into the impact of the COVID-19 pandemic on MDRO isolation and has important implications for infection control and prevention efforts in healthcare facilities. Age, DRG-weight, and longer hospital stays further increased the risk of MDRO isolation. Thus, it is imperative to improve and follow hospital protocols to prevent healthcare-associated infections.

Treatment seeking and antibiotic use for urinary tract infection symptoms in the time of COVID-19 in Tanzania and Uganda

Background

There is still little empirical evidence on how the outbreak of coronavirus disease 2019 (COVID-19) and associated regulations may have disrupted care-seeking for non-COVID-19 conditions or affected antibiotic behaviours in low- and middle-income countries (LMICs). We aimed to investigate the differences in treatment-seeking behaviours and antibiotic use for urinary tract infection (UTI)-like symptoms before and during the pandemic at recruitment sites in two East African countries with different COVID-19 control policies: Mbarara, Uganda and Mwanza, Tanzania.

Methods

In this repeated cross-sectional study, we used data from outpatients (pregnant adolescents aged >14 and adults aged >18) with UTI-like symptoms who visited health facilities in Mwanza, Tanzania and Mbarara, Uganda. We assessed the prevalence of self-reported behaviours (delays in care-seeking, providers visited, antibiotics taken) at three different time points, labelled as 'pre-COVID-19 phase' (February 2019 to February 2020), 'COVID-19 phase 1' (March 2020 to April 2020), and 'COVID-19 phase 2' (July 2021 to February 2022).

Results

In both study sites, delays in care-seeking were less common during the pandemic than they were in the pre-COVID phase. Patients in Mwanza, Tanzania had shorter care-seeking pathways during the pandemic compared to before it, but this difference was not observed in Mbarara, Uganda. Health centres were the dominant sources of antibiotics in both settings. Over time, reported antibiotic use for UTI-like symptoms became more common in both settings. During the COVID-19 phases, there was a significant increase in self-reported use of antibiotics like metronidazole (<30% in the pre-COVID-19 phase to 40% in COVID phase 2) and doxycycline (30% in the pre-COVID-19 phase to 55% in COVID phase 2) that were not recommended for treating UTI-like symptoms in the National Treatment Guidelines in Mbarara, Uganda.

Conclusions

There was no clear evidence that patients with UTI-like symptoms attending health care facilities had longer or more complex treatment pathways despite strict government-led interventions related to COVID-19. However, antibiotic use increased over time, including some antibiotics not recommended for treating UTI, which has implications for future antimicrobial resistance.

A COVID-19 Silver Lining-Decline in Antibiotic Resistance in Ischemic Leg Ulcers during the Pandemic: A 6-Year Retrospective Study from a Regional Tertiary Hospital (2017-2022)

Antibiotic resistance (AR) associated with chronic limb-threatening ischemia (CLTI) poses additional challenges for the management of ischemic leg ulcers, increasing the likelihood of severe outcomes. This study assessed AR prevalence in bacteria isolated from CLTI-associated leg ulcers before (1 January 2017-10 March 2020; n = 69) and during (11 March 2020-31 December 2022; n = 59) the COVID-19 pandemic from patients admitted with positive wound cultures to a regional hospital in Chiang Mai (Thailand). There was a marked reduction in AR rates from 78% pre-pandemic to 42% during the pandemic (p < 0.0001), with rates of polymicrobial infections 22 percentage points lower (from 61% to 39%, respectively; p = 0.014). There were reduced AR rates to amoxicillin/clavulanate (from 42% to 4%; p < 0.0001) and ampicillin (from 16% to 2%; p = 0.017), as well as multidrug resistance (19% to 8%; p = 0.026). Factors associated with increased AR odds were polymicrobial infections (adjusted odds ratio (aOR) 5.6 (95% CI 2.1, 15.0); p = 0.001), gram-negative bacteria (aOR 7.0 (95% CI 2.4, 20.5); p < 0.001), and prior use of antibiotics (aOR 11.9 (95% CI 1.1, 128.2); p = 0.041). Improvements in infection control measures and hygiene practices in the community during the pandemic were likely key factors contributing to lower AR rates. Thus, strategic public health interventions, including community education on hygiene and the informed use of antibiotics, may be crucial in mitigating the challenges posed by AR in CLTI. Further, advocating for more judicious use of empirical antibiotics in clinical settings can balance effective treatment against AR development, thereby improving patient outcomes.

Antimicrobial prescribing in a secondary care setting during the COVID-19 pandemic

Background

Increased antimicrobial resistance patterns lead to limited options for antimicrobial agents, affecting patient health and increasing hospital costs.

Objectives

To investigate the antimicrobial prescribing patterns at two district hospitals in Northern Ireland before and during the COVID-19 pandemic.

Methods

A mixed prospective-retrospective study was designed to compare pre- and during pandemic antimicrobial prescribing data in both hospitals using a Global Point Prevalence Survey.

Results

Of the 591 patients surveyed in both hospitals, 43.8% were treated with 402 antimicrobials. A total of 82.8% of antimicrobial prescriptions were for empirical treatment. No significant difference existed in numbers of patients treated or antimicrobials used before and during the pandemic. There was a slight decrease of 3.3% in the compliance rate with hospital antimicrobial guidelines during the pandemic when compared with the pre-pandemic year of 2019, when it was 69.5%. Treatment based on patients' biomarker data also slightly decreased from 83.5% pre-pandemic (2019) to 81.5% during the pandemic (2021).

Conclusions

There was no overall significant impact of the pandemic on the antimicrobial prescribing patterns in either hospital when compared with the pre-pandemic findings. The antimicrobial stewardship programmes would appear to have played an important role in controlling antimicrobial consumption during the pandemic.

Microbiological profile of multidrug resistant bacteria before and during COVID-19 in CHU Mohammed VI

Background and Objectives

A new type of corona virus has caused Corona virus disease-19 and, subsequently, a global pandemic. All individuals are prone to the disease, so drastic measures were taken to prevent its spread. This study aimed to evaluate the impact of COVID-19 on the progression of the antimicrobial resistance rate by comparing two periods: before and during COVID-19.

Materials and Methods

We used a cross-sectional design to investigate the Antimicrobial Resistance (AMR) rate before (03/2019 to 03/2020) and during COVID-19 (03/2020 to 03/2021) in a University Hospital in Marrakech. The data were analyzed using SPSS Version 25.0.

Results

Among the 7106 specimens, there was a significant increase in the multidrug-resistant bacterial from 27.38% to 35.87% during COVID-19 (p<0.001), particularly in blood culture, cerebrospinal fluid, catheter, and pus. However, there was a non-significant change in puncture fluid, expectoration, protected distal sampling, joint fluid, stool culture, and genital sampling. A decrease in Multidrug-resistant bacteria (MDRB) was observed only in cytobacteriological urine tests (p<0.05). According to species, there was an increase in extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, and methicillin-resistant Staphylococcus aureus.

Conclusion

In our study, it is particularly noticeable that the MDRB has increased. These results highlight the importance that the pandemic has not been able to slow the progression.

Leveraging the COVID-19 pandemic as a natural experiment to assess changes in antibiotic use and antibiotic-resistant E. coli carriage in semi-rural Ecuador

The coronavirus 2019 (COVID-19) pandemic has had significant impacts on health systems, population dynamics, public health awareness, and antibiotic stewardship, which could affect antibiotic resistant bacteria (ARB) emergence and transmission. In this study, we aimed to compare knowledge, attitudes, and practices (KAP) of antibiotic use and ARB carriage in Ecuadorian communities before versus after the COVID-19 pandemic began. We leveraged data collected for a repeated measures observational study of third-generation cephalosporin-resistant E. coli (3GCR-EC) carriage among children in semi-rural communities in Quito, Ecuador between July 2018 and September 2021. We included 241 households that participated in surveys and child stool sample collection in 2019, before the pandemic, and in 2021, after the pandemic began. We estimated adjusted Prevalence Ratios (aPR) and 95% Confidence Intervals (CI) using logistic and Poisson regression models. Child antibiotic use in the last 3 months declined from 17% pre-pandemic to 5% in 2021 (aPR: 0.30; 95% CI 0.15, 0.61) and 3GCR-EC carriage among children declined from 40 to 23% (aPR: 0.48; 95% CI 0.32, 0.73). Multi-drug resistance declined from 86 to 70% (aPR: 0.32; 95% CI 0.13; 0.79), the average number of antibiotic resistance genes (ARGs) per 3GCR-EC isolate declined from 9.9 to 7.8 (aPR of 0.79; 95% CI 0.65, 0.96), and the diversity of ARGs was lower in 2021. In the context of Ecuador, where COVID-19 prevention and control measures were strictly enforced after its major cities experienced some of the world's the highest mortality rates from SARS-CoV-2 infections, antibiotic use and ARB carriage declined in semi-rural communities of Quito from 2019 to 2021.

Bacterial Pathogens and Antimicrobial Susceptibility Patterns of Urinary Tract Infections in Children during COVID-19 2019-2020: A Large Tertiary Care Center in Saudi Arabia

BACKGROUND

One of the most prevalent bacterial infections in children is urinary tract infection (UTI), which has become a major concern with increasing resistance of the pathogens to the routinely used antimicrobial agents. The aim of the study is to determine the antimicrobial susceptibility patterns of pediatric UTI-causing pathogens, including ESBL-producing bacteria, in Saudi Arabia.

METHODS

This cross-sectional retrospective study was conducted to ascertain the frequency of isolation and the antimicrobial resistance pattern of uropathogens among children aged 0-15 years. The data from the urine cultures was collected during 2019-2020 at the King Fahad Medical City, a major tertiary hospital in Riyadh, Saudi Arabia. A total of 1022 urine samples from patients diagnosed with urinary tract infections (UTIs) were collected for this study. Microbial species present in the samples were cultured and identified using standard biochemical techniques. To assess the resistance of these strains to antimicrobial drugs, an in vitro method was employed, and the criteria set by the Clinical Laboratory Standard Institute (CLSI) were followed. In addition, a double-disc synergy test was conducted to identify strains of E. coli that produce extended-spectrum beta-lactamase (ESBL).

RESULTS

The predominant pathogens were E. coli (58.6%), followed by Klebsiella sp. (23.9%). E. coli isolates were more sensitive to meropenem and ertapenem in 99.2% of cases, followed by amikacin (99%). Klebsiella sp. were sensitive to amikacin in 97.1% of cases, followed by meropenem and ertapenem (92.2% in both). The highest sensitivities of antimicrobials toward ESBL were for meropenem and ertapenem (100% in both), followed by amikacin (99%).

CONCLUSIONS

Our study recommends using local antibiotic sensitivity data for empirical UTI treatment. Amikacin, ertapenem, and meropenem are effective intravenous options. Cephalosporin, cefuroxime, amoxicillin/clavulanic acid, and nitrofurantoin are suitable oral choices. No significant changes in antimicrobial susceptibility were observed during the COVID-19 pandemic. Further research is needed to assess potential pandemic-related alterations.

Antibiotic resistance and consumption before and during the COVID-19 pandemic in Valle del Cauca, Colombia

Objective

To assess changes in antibiotic resistance of eight of the World Health Organization priority bug-drug combinations and consumption of six antibiotics (ceftriaxone, cefepime, piperacillin/tazobactam, meropenem, ciprofloxacin, vancomycin) before (March 2018 to July 2019) and during (March 2020 to July 2021) the COVID-19 pandemic in 31 hospitals in Valle del Cauca, Colombia.

Methods

This was a before/after study using routinely collected data. For antibiotic consumption, daily defined doses (DDD) per 100 bed-days were compared.

Results

There were 23 405 priority bacterial isolates with data on antibiotic resistance. The total number of isolates increased from 9 774 to 13 631 in the periods before and during the pandemic, respectively. While resistance significantly decreased for four selected bug-drug combinations (Klebsiella pneumoniae, extended spectrum beta lactamase [ESBL]-producing, 32% to 24%; K. pneumoniae, carbapenem-resistant, 4% to 2%; Pseudomonas aeruginosa, carbapenem-resistant, 12% to 8%; Acinetobacter baumannii, carbapenem-resistant, 23% to 9%), the level of resistance for Enterococcus faecium to vancomycin significantly increased (42% to 57%). There was no change in resistance for the remaining three combinations (Staphylococcus aureus, methicillin-resistant; Escherichia coli, ESBL-producing; E. coli, carbapenem-resistant). Consumption of all antibiotics increased. However, meropenem consumption decreased in intensive care unit settings (8.2 to 7.1 DDD per 100 bed-days).

Conclusions

While the consumption of antibiotics increased, a decrease in antibiotic resistance of four bug-drug combinations was observed during the pandemic. This was possibly due to an increase in community-acquired infections. Increasing resistance of E. faecium to vancomycin must be monitored. The findings of this study are essential to inform stewardship programs in hospital settings of Colombia and similar contexts elsewhere.

Antibiotic resistance associated with the COVID-19 pandemic: a systematic review and meta-analysis

BACKGROUND

COVID-19 and antimicrobial resistance (AMR) are two intersecting global public health crises.

OBJECTIVE

We aimed to describe the impact of the COVID-19 pandemic on AMR across health care settings.

DATA SOURCE

A search was conducted in December 2021 in WHO COVID-19 Research Database with forward citation searching up to June 2022.

STUDY ELIGIBILITY

Studies evaluating the impact of COVID-19 on AMR in any population were included and influencing factors were extracted. Reporting of enhanced infection prevention and control and/or antimicrobial stewardship programs was noted.

METHODS

Pooling was done separately for Gram-negative and Gram-positive organisms. Random-effects meta-analysis was performed.

RESULTS

Of 6036 studies screened, 28 were included and 23 provided sufficient data for meta-analysis. The majority of studies focused on hospital settings (n = 25, 89%). The COVID-19 pandemic was not associated with a change in the incidence density (incidence rate ratio 0.99, 95% CI: 0.67-1.47) or proportion (risk ratio 0.91, 95% CI: 0.55-1.49) of methicillin-resistant Staphylococcus aureus or vancomycin-resistant enterococci cases. A non-statistically significant increase was noted for resistant Gram-negative organisms (i.e. extended-spectrum beta-lactamase, carbapenem-resistant Enterobacterales, carbapenem or multi-drug resistant or carbapenem-resistant Pseudomonas aeruginosa or Acinetobacter baumannii, incidence rate ratio 1.64, 95% CI: 0.92-2.92; risk ratio 1.08, 95% CI: 0.91-1.29). The absence of reported enhanced infection prevention and control and/or antimicrobial stewardship programs initiatives was associated with an increase in gram-negative AMR (risk ratio 1.11, 95% CI: 1.03-1.20). However, a test for subgroup differences showed no statistically significant difference between the presence and absence of these initiatives (p 0.40).

CONCLUSION

The COVID-19 pandemic may have hastened the emergence and transmission of AMR, particularly for Gram-negative organisms in hospital settings. But there is considerable heterogeneity in both the AMR metrics used and the rate of resistance reported across studies. These findings reinforce the need for strengthened infection prevention, antimicrobial stewardship, and AMR surveillance in the context of the COVID-19 pandemic.

Flare of the silent pandemic in the era of the COVID-19 pandemic: Obstacles and opportunities

A noteworthy public health problem, antimicrobial resistance (AMR) has been impeded in many ways by the coronavirus disease 2019 (COVID-19) pandemic. This narrative review discusses the two-sided impact of COVID-19 on the magnitude of AMR. The pandemic has put tremendous strain on healthcare systems, diverting resources, personnel, and attention away from AMR diagnosis and management toward COVID-19 diagnosis and contact tracking and tracing. AMR research has been severely hampered, and surveillance and antimicrobial stewardship (AMS) programs have been de-emphasized, delayed, or halted. Antibiotics, particularly broad-spectrum, were prescribed more frequently without diagnostic confirmation of bacterial infection than before the pandemic. Nonetheless, the COVID-19 pandemic has highlighted the vulnerability of healthcare systems in controlling infectious disease threats and raised awareness of the importance of infection prevention and control. Yet, the pandemic has created opportunities to capitalize on positive effects on AMR management. The review concludes that it is now more important than ever to focus on AMR and strengthen AMS programs to ensure appropriate antibiotic use and other AMR prevention measures in healthcare. We must ensure that one of the COVID-19 legacies is increased support for AMR research, diagnostic implementation, appropriate diagnostic stewardship, and the strengthening of our health systems. The COVID-19 pandemic has demonstrated that prevention is better than cure. Countries will need to step up their efforts to combat AMR as a multidisciplinary community. We must prepare our public health systems to combat multiple threats at the same time.

Trends in the Rates of Extended-Spectrum-β-Lactamase-Producing Enterobacterales Isolated from Urine Cultures during the COVID-19 Pandemic in Ontario, Canada

Worldwide, extended-spectrum β-lactamase (ESBL) rates are increasing at an alarming level with increasing rates of health care exposures, international travel, and antibiotic usage. In this study, we investigated whether enhanced social isolation, travel restrictions, and the reduced use of antibiotics in Ontario, Canada during coronavirus disease 2019 (COVID-19) pandemic had an impact on ESBL rates in urine cultures collected from the community and long-term-care (LTC) facilities across the province. Data from a total of 8.6 million urine cultures performed at LifeLabs Ontario from 2016 to 2021 were utilized for analysis. ESBL-producing Escherichia coli (ESBL Escherichia coli) and ESBL Klebsiella pneumoniae were identified using standard operating procedures. Data trends were estimated by interrupted time series (ITS) regression analysis. Among 2.3 million positive urine cultures, 48.9% and 7.2% grew E. coli and K. pneumoniae, of which 5.8% and 3.3% produced ESBLs, respectively. While the overall rate of ESBL isolation was higher in the pandemic period than in the prepandemic period, by ITS regression analysis of the monthly rates of ESBL isolation, decreasing trends were noted for ESBL E. coli in both the community and LTC facilities and for ESBL K. pneumoniae in the community. The ESBL K. pneumoniae rates in LTC facilities continued to increase throughout the COVID-19 period. By subgroup analysis for different genders, age groups, and local health integration network (LHIN) units, similar trends were seen in most cases (P < 0.05), except for a few densely populated LHINs where rate changes were not statistically significant. IMPORTANCE Community-onset urinary tract infections (UTIs) caused by ESBL-producing Enterobacterales, particularly E. coli and K. pneumoniae, are a major public health concern. In this study, we assessed the impact of COVID-19 on ESBL rates in urine cultures in Ontario, Canada. Our results show the recent epidemiology of ESBL-producing Enterobacterales in urine cultures from both the community and LTC facilities in Ontario, Canada, and the impact of COVID-19 restrictions on ESBL trends for the entire province as well as different subgroups of the population based on demographic and geographic characteristics. Our results may have important public health implications in the context of the gradual easing of COVID-19 restrictions.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital

Background

There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital.

Methods

We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time.

Results

Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016–1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96).

Conclusions

In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01114-x.

Investigation of Antibiotic Resistome in Hospital Wastewater during the COVID-19 Pandemic: Is the Initial Phase of the Pandemic Contributing to Antimicrobial Resistance?

Since the COVID-19 pandemic started, there has been much speculation about how COVID-19 and antimicrobial resistance may be interconnected. In this study, untreated wastewater was sampled from Hospital A designated to treat COVID-19 patients during the first wave of the COVID-19 pandemic alongside Hospital B that did not receive any COVID-19 patients. Metagenomics was used to determine the relative abundance and mobile potential of antibiotic resistant genes (ARGs), prior to determining the correlation of ARGs with time/incidence of COVID-19. Our findings showed that ARGs resistant to macrolides, sulfonamides, and tetracyclines were positively correlated with time in Hospital A but not in Hospital B. Likewise, minor extended spectrum beta-lactamases (ESBLs) and carbapenemases of classes B and D were positively correlated with time, suggesting the selection of rare and/or carbapenem-resistant genes in Hospital A. Non-carbapenemase bla_VEB also positively correlated with both time and intI1 and was copresent with other ARGs including carbapenem-resistant genes in 6 metagenome-assembled genomes (MAGs). This study highlighted concerns related to the dissemination of antimicrobial resistance (AMR) during the COVID-19 pandemic that may arise from antibiotic use and untreated hospital wastewater.

Antimicrobial resistance pattern in clinical Escherichia coli and Pseudomonas aeruginosa isolates obtained from a secondary-care hospital prior to and during the COVID-19 pandemic in Kuwait

Introduction

The study objective was to compare the prevalence of antimicrobial resistance (AMR) in clinical Escherichia coli and Pseudomonas aeruginosa isolates obtained from a secondary-care hospital prior to and during the COVID-19 pandemic in Kuwait.

Methods

A retrospective descriptive study was conducted based on AMR profiles of clinical Escherichia coli and Pseudomonas aeruginosa isolates. The AMR data represented isolates from five specimen types (body fluids; blood; respiratory; wound, bone, or other tissues; and urine) of patients admitted to four wards (surgical, medical, pediatric, and maternal-postnatal). Tested isolates between January 2019 and February 2020 represented the pre-COVID-19 pandemic period in Kuwait, whereas those from February 2020 until April 2021 represented the 'during COVID-19' period.

Results

A total of 1,303 isolates (57.2% E. coli and 42.8% P. aeruginosa) were analyzed. For ceftazidime, ertapenem and meropenem, the prevalence of AMR in E. coli was significantly (p<0.05) lower in pre-COVID-19 wards compared to that during COVID-19, whereas for other antibiotics (i.e., cefepime, gentamicin, and trimethoprim/sulfamethoxazole), the prevalence of AMR in pre-COVID-19 was significantly higher than that during COVID-19. The prevalence of AMR to gentamicin in P. aeruginosa isolates from non-COVID-19 wards (52.8%) was significantly higher (p<0.001) than that from COVID-19 wards (35.0%) and from the pre-COVID-19 period (32.9%). The multidrug-resistance (MDR) prevalence was 37.4% for E. coli and 32.1% for P. aeruginosa isolates. The odds of MDR in E. coli isolates from the COVID-19 medical wards were significantly lower (OR=0.27, [95%CI: 0.09-0.80], p=0.018) compared to the pre-COVID-19 wards. The odds of MDR E. coli and P. aeruginosa isolates by COVID-19 status stratified by specimen type were not different (p>0.05).

Conclusions

No major differences in AMR in E. coli and P. aeruginosa prevalence by specimen type and wards prior to and during the COVID-19 pandemic was observed at this hospital. The high reported MDR prevalence calls for better infection control and prevention.

Prevalence and Antimicrobial Resistance of Bloodstream Infections Caused by ESKAPEEc Pathogens: A Five-year Analysis

Background: Antimicrobial resistance in ESKAPEEc (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter species, and Escherichia coli) pathogens causing bloodstream infections (BSIs) is a growing threat to clinicians and public health. Objectives: Our purpose was to determine the prevalence and susceptibility of ESKAPEEcs causing BSI over five years (2016 to 2020) at a large tertiary hospital in Istanbul, Turkey. Methods: Of 2591 unique isolates obtained from blood culture specimens, 1.281 (49.4%) were positive for ESKAPEEc pathogens. The ESKAPEEc rates increased from 2016 to 2019 and decreased during the COVID-19 pandemic. Results: The most common pathogen was K. pneumoniae (34.3%). Carbapenem resistant (CR) K. pneumoniae was 61.8% and A. baumannii was 90.4%. The percentages of methicillin-resistant S. aureus (MRSA) and vancomycin-resistant E. faecium (VRE) were 38.6% and 29.4%, respectively. Conclusions: Our findings showed a high incidence of ESKAPEEc and AMR in BSIs. Antibiotic policies and restrictions in health care settings and the community will play an essential role in the solution in the future.

Knowledge and perceptions of Australian postgraduate veterinary students prior to formal education of antimicrobial use and antimicrobial resistance

Antimicrobial resistance (AMR) is widely perceived as a threat to human and animal health and a significant One Health issue with extensive and complex factors contributing to its occurrence and spread. Previous studies have surveyed human and animal health professionals to determine their perceptions regarding AMR and antimicrobial use (AMU). There are limited studies exploring the understanding of veterinary students despite their critical role as future antimicrobial prescribers. A cross-sectional survey was administered to an entire cohort of Doctor of Veterinary Medicine Year 2 (DVM2) students (n = 136) to investigate their knowledge and perceptions regarding AMR and AMU prior to formal education on this issue. Ninety students (66.2% of the cohort) completed the survey. There was overwhelming agreement regarding the immediacy of the problem, with 84.4% of students indicating that 'We must take action on AMR'. Despite more than 94.4% of students correctly defining AMR, specific knowledge regarding AMR impact, contributory causes to AMR and strategies to solve the challenge of AMR was variable. Most students perceived livestock producers to have a significant role in the perpetuation of AMR due to AMU for prophylaxis (71.1% substantial/moderate contribution) and treatment (56.7% substantial/moderate contribution). Over a third of respondents (37.8%) were unsure if AMR could spread from animals to humans. Respondents perceived that various groups (dentists, doctors, veterinarians, professional organisations) are all important in ameliorating the issue of AMR. The implementation of restrictive measures to reduce veterinary prescription of antimicrobials was viewed as less important than strategies involving education, hygiene, surveillance, and guideline development/availability. To encourage the development of good antimicrobial stewardship (AMS) practices, professional veterinary education needs to foster an understanding of the scientific, behavioural and social issues that contribute to AMR and inappropriate AMU, as well as prescribers' personal contribution to AMR perpetuation and amelioration.

Antimicrobial Resistance as a Global Health Threat: The Need to Learn Lessons from the COVID-19 Pandemic

The global COVID-19 pandemic has exacerbated existing health, social, and economic challenges and threatened progress towards achieving the UN sustainable development goals. We discuss lessons learned from the COVID-19 pandemic for global policymaking for health security governance, with a particular focus on antimicrobial resistance. We identify One Health as the primary foundation of public health risk management owing to the collaborative, multidisciplinary, and multisectoral efforts that underpin the One Health approach and that enhance understanding of the complex interactions at the human-animal-environment interface. We discuss the narrow human-centric focus of the One Health approach, highlight the underrepresentation of the environmental sector in One Health networks, and encourage greater representation from the environmental sector. Furthermore, we highlight the importance of the social sciences for health security research and the need for effective communication and trust. Finally, we underscore the importance of strengthened and collaborative health, social care, and disaster management systems. The application of these lessons will facilitate holistic, multisectoral, collaborative, and ethical actions on antimicrobial resistance.

Knowledge and Practice of Antibiotic Management and Prudent Prescribing among Polish Medical Doctors

Antimicrobial resistance (AMR) is an urgent public health issue. The role of medical doctors in proper antibiotic use is crucial. The aim of this study was to evaluate the knowledge and practices of Polish doctors of antimicrobial prescribing and antibiotic resistance. The study group consisted of 504 medical doctors with an average age 32.8 ± 5.9 years, mostly women (65%). The paper questionnaire was developed on the basis of a survey tool developed by the European Centre for Disease Prevention and Control (ECDC) and Public Health England (PHE). According to our study, physicians were aware that: taking antibiotics has side effects, antibiotics cannot be used against viruses, unnecessary use of antibiotics leads to AMR and that healthy people can carry resistant bacteria (each item ≥98% correct responses). Only 47% of respondents knew that the use of antibiotics as growth stimulants in livestock is illegal in the EU. Of the respondents, 98.61% saw the connection between prescribing antibiotics and AMR. However, 65.28% of the respondents reported a lack of appropriate materials on AMR counseling. Nearly 92.5% of participants "never" or "rarely" gave out resources on prudent antibiotic use. Physicians in Poland underestimate the role of hand hygiene in stimulating antibiotic resistance (ABR) (74.4%), while demonstrating satisfying knowledge about antimicrobial use, the clinical application of antimicrobial guidelines and prevention of ABR. However, educational interventions are needed to help lead challenging communication with assertive patients. Appropriate patient resources would be helpful in reaching this goal.

Does the COVID Pandemic Modify the Antibiotic Resistance of Uropathogens in Female Patients? A New Storm?

Urinary tract infections (UTIs) represent a common pathology among female patients, leading to overprescribing antibiotics, globally. The emergence of the COVID-19 pandemic has dramatically increased the incidence of this particular viral pneumonia with secondary bacterial superinfection, resulting in continuous therapeutic or prophylactic recommendations of antibiotic treatment; thus, an updated analysis of current antimicrobial resistance among uropathogens is mandatory. This cross-sectional retrospective study conducted in two university hospitals in Bucharest, Romania analyzed 2469 positive urine cultures, among two different periods of 6 months, before and during the COVID-19 pandemic. The most common pathogen was Escherichia coli 1505 (60.95%), followed by Klebsiella spp. 426 (17.25%). Enterococcus spp. was the leading Gram-positive pathogen 285 (11.54%). In gram negative bacteria, in almost all cases, an increased in resistance was observed, but the highest increase was represented by quinolones in Klebsiella spp., from 16.87% to 35.51% and Pseudomonas from 30.3% to 77.41%; a significant increase in resistance was also observed for carbapenems. Surprisingly, a decrease in resistance to Penicillin was observed in Enterococcus spp., but the overall tendency of increased resistance is also maintained for gram positive pathogens. The lack of data on the influence of the COVID-19 pandemic on uropathogens’ resistance promotes these findings as important for every clinician treating UTIs and for every specialist in the medical field in promoting reasonable recommendations of antibiotic therapies.

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.

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.

Cropping Up Crisis at the Nexus Between COVID-19 and Antimicrobial Resistance (AMR) in Africa: A Scoping Review and Synthesis of Early Evidence

In this study, we aim to synthesize some evidence on the impacts that coronavirus disease 2019 (COVID-19) is having on the epidemiology of antimicrobial resistance (AMR) in Africa since it was declared a global pandemic by the WHO in March 2020.

A scoping review was undertaken by collecting and curating relevant resources from peer-reviewed articles and also from the gray literature. Mixed approaches of extracting data (qualitative and quantitative) were employed in synthesizing evidence, as suggested by the Health Evidence Network.

A model constructed based on the synthesis of early evidence available on the effects of factors linked to COVID-19 in impacting the evolution of AMR in Africa predicted that, in cumulative terms, those factors favoring the evolution of AMR outpace those disfavoring it by no less than three folds.

COVID-19 is likely fueling the evolution of AMR almost unhindered in Africa. Due to the recognition of this crisis, concerted efforts for resource mobilization and global cooperation are needed to tackle it.

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.

COVID-19 pandemic and antimicrobial resistance in developing countries

A wide range of antimicrobial agents were touted as potential remedies during the COVID-19 pandemic. While both developed and developing countries have recorded an increase in the use of antimicrobial drugs, use and misuse have occurred to a far greater degree in developing countries. This can have deleterious consequences on antimicrobial resistance, especially when various developing countries have already reported the emergence of various drug-resistant organisms even before the pandemic. Telemedicine services, societal and cultural pressures, and bacterial co-infections can predispose to overwhelming antimicrobial prescriptions. The emergence of new multidrug resistance species is a major concern for the developing world especially since health services are already overburdened and lack the diagnostic capabilities and basic amenities for infection prevention and control. This can lead to outbreaks and the rampant spread of such microorganisms. Improper waste management and disposal from hospitals and communities establish freshwater runoffs as hubs of various microorganisms that can predispose to the rise of multidrug-resistant species. Microplastics' ability to act as vectors for antibiotic-resistant organisms is also particularly concerning for lower-middle-income countries. In this review, we aim to study the impact of antimicrobial use during the COVID-19 pandemic and antimicrobial resistance in lower middle-income countries, by understanding various determinants of resistance unique to the developing world and exploring solutions to combat the problem.

COVID-19: Impact on prescribing and antimicrobial resistance

The onset of the COVID-19 pandemic challenged health-care systems focusing their activity on patients infected with SARS-CoV-2. Previous experience with co-infections and superinfections in patients infected with other coronaviruses (SARS-CoV and MERS), the influenza patients admitted to hospitals and prevention of the unknown led to the increased empirical use of broad-spectrum antibiotics in hospitals. The breakdown of antimicrobial stewardship and infection control programs determine an increase in infections due to multi-drug-resistant bacteria, particularly in intensive care units. Most of these infections are related to high-risk carbapenemase-producing clones and occasionally with resistance to new β-lactamβ-lactamase inhibitor combinations. On the contrary, in the primary care, there has been a decrease in the use of antimicrobials during the first wave, although it would not have had a significant impact on pathogens associated with community-acquired infections. The accumulated experience reaffirms the need to maintain antimicrobial stewardship and infection control programs in future health crises.

Bacterial and fungal growth in sputum cultures from 165 COVID-19 pneumonia patients requiring intubation: evidence for antimicrobial resistance development and analysis of risk factors

BACKGROUND

Coronavirus SARS-CoV-2 causes COVID-19 illness which can progress to severe pneumonia. Empiric antibacterials are often employed though frequency of bacterial coinfection superinfection is debated and concerns raised about selection of bacterial antimicrobial resistance. We evaluated sputum bacterial and fungal growth from 165 intubated COVID-19 pneumonia patients. Objectives were to determine frequency of culture positivity, risk factors for and outcomes of positive cultures, and timing of antimicrobial resistance development.

METHODS

Retrospective reviews were conducted of COVID-19 pneumonia patients requiring intubation admitted to a 1058-bed four community hospital system on the east coast United States, March 1 to May 1, 2020. Length of stay (LOS) was expressed as mean (standard deviation); 95% confidence interval (95% CI) was computed for overall mortality rate using the exact binomial method, and overall mortality was compared across each level of a potential risk factor using a Chi-Square Test of Independence. All tests were two-sided, and significance level was set to 0.05.

RESULTS

Average patient age was 68.7 years and LOS 19.9 days. Eighty-three patients (50.3% of total) originated from home, 10 from group homes (6.1% of total), and 72 from nursing facilities (43.6% of total). Mortality was 62.4%, highest for nursing home residents (80.6%). Findings from 253 sputum cultures overall did not suggest acute bacterial or fungal infection in 73 (45%) of 165 individuals sampled within 24 h of intubation. Cultures ≥ 1 week following intubation did grow potential pathogens in 72 (64.9%) of 111 cases with 70.8% consistent with late pneumonia and 29.2% suggesting colonization. Twelve (10.8% of total) of these late post-intubation cultures revealed worsened antimicrobial resistance predominantly in Pseudomonas, Enterobacter, or Staphylococcus aureus.

CONCLUSIONS

In severe COVID-19 pneumonia, a radiographic ground glass interstitial pattern and lack of purulent sputum prior to/around the time of intubation correlated with no culture growth or recovery of normal oral flora ± yeast. Discontinuation of empiric antibacterials should be considered in these patients aided by other clinical findings, history of prior antimicrobials, laboratory testing, and overall clinical course. Continuing longterm hospitalisation and antibiotics are associated with sputum cultures reflective of hospital-acquired microbes and increasing antimicrobial resistance.

TRIAL REGISTRATION

Not applicable as this was a retrospective chart review study without interventional arm.

Antibiotics susceptibility of Escherichia coli isolates from clinical specimens before and during COVID-19 pandemic

Background and Objectives

Escherichia coli is a Gram-negative organism causing mild to severe infections, with a wide spectrum range of organs involved. The study aimed to describe antibiotics susceptibility of E. coli from clinical specimens from October 11, 2019 to September 11, 2020.

Materials and Methods

Study was conducted retrospectively in a private microbiology laboratory in Mataram Indonesia. Period of study divided as two groups after WHO declared COVID-19 as pandemic by March 11, 2020; group A including the specimen related to September 2019 to March 11^th 2020 and group B including the specimens related to March 11^th 2020 to September 2020. All clinical specimens were subjected to identify E. coli isolates and their antibiotics susceptibility using WHO-NET 5.6 version.

Results

Totally, 148 E. coli isolates were found in group A and 62 isolates in group B. Prevalence of extended-spectrum beta lactamase (ESBL)- producing E. coli in group A was 50% and in group B was 20.9% with significantly difference (p<0.05). There was an increase in susceptibility to 10/16 antibiotics; where 3 antibiotics ofloxacin, aztreonam, and fosfomycin were significant (p<0.05). There was a significant decrease in susceptibility to the antibiotics piperacillin (p=0.012), amoxicillin (p=0.002), cefadroxil (p=0.036) and ampicillin (p=0.036). Type of infections between two groups: musculoskeletal infections, pneumonia, urinary tract infections and sepsis were not significant.

Conclusion

Reduced number of E. coli isolates between two groups with decrease of ESBL-producing E. coli contribute in dynamics of antibiotics susceptibility. The longer period of analysis is needed to be done, due to the ongoing COVID-19 pandemic.

Antimicrobial resistance and COVID-19 syndemic: Impact on public health

The COVID -19 pandemic has had a catastrophic impact on the global economy and the healthcare industry. Unfortunately, the scientific community still hasn't discovered a definite cure for this virus. Also, owing to the unscrupulous use of antibiotics in wake of the current situation, another ongoing pandemic of antimicrobial resistance (AMR) has been entirely eclipsed. However, increased compliance to infection control measures like hand hygiene (both at hospital and community level), and restricted travel might be favorable. It is evident that the AMR strategies will be impacted disproportionately varying with the respective policies followed by the countries and hospitals to deal with the pandemic. The vaccination drive initiated globally has provided a glimmer of hope. In this article, the possible reciprocity between the two contemporaneous pandemics has been addressed. The world needs to be vigilant to punctuate the symphony between these lethal threats to global health. The restraint to combat against AMR will be boosted as our discernment of the problem also changes with the epidemiological interplay becoming more apparent in near future.

The potential impact of the COVID-19 pandemic on antimicrobial resistance and antibiotic stewardship

The rapid emergence and spread of antimicrobial resistance continue to kill an estimated 700,000 people annually, and this number is projected to increase ten-fold by 2050. With the lack of data, it is uncertain how the COVID-19 pandemic will affect antimicrobial resistance. Severe disruption of research, innovation, global health programs, and compromised antimicrobial stewardship, infection prevention and control programs, especially in low-and middle-income countries, could affect antimicrobial resistance. However, factors such as strict lockdown, social distancing, vaccination, and the extensive implementation of hand hygiene and face masks, with limited international travel and migration, may also contribute to decreasing AMR. Although the impact of COVID-19 on AMR is global, the adverse effect is likely to be worse in LMICs. In this article, we explore the possible impact of the current pandemic on antibiotic resistance.

Learning From Mistakes: The Role of Phages in Pandemics

The misuse of antibiotics is leading to the emergence of multidrug-resistant (MDR) bacteria, and in the absence of available treatments, this has become a major global threat. In the middle of the recent severe acute respiratory coronavirus 2 (SARS-CoV-2) pandemic, which has challenged the whole world, the emergence of MDR bacteria is increasing due to prophylactic administration of antibiotics to intensive care unit patients to prevent secondary bacterial infections. This is just an example underscoring the need to seek alternative treatments against MDR bacteria. To this end, phage therapy has been proposed as a promising tool. However, further research in the field is mandatory to assure safety protocols and to develop appropriate regulations for its use in clinics. This requires investing more in such non-conventional or alternative therapeutic approaches, to develop new treatment regimens capable of reducing the emergence of MDR and preventing future global public health concerns that could lead to incalculable human and economic losses.

Antimicrobial resistance during the COVID-19 pandemic: the missing patient perspective

While the use of antibiotics for secondary infections in COVID-19 has been described in scientific literature and guidelines have been issued for their appropriate use, the importance of listening to patients in a systematic manner has often been overlooked. To highlight this issue, we spoke with patients about their experiences with antibiotics as treatment for COVID-19 and their understanding of antimicrobial resistance (AMR). We found that there is a general lack of awareness of the risks of AMR, and even when patients are knowledgeable, fear of COVID-19 and pressure from healthcare providers often override considerations for appropriate use. We present case examples of three patients' experiences and provide recommendations for health systems, healthcare providers, and patients or caregivers on actions they can each take to reduce the risk of AMR during and beyond the COVID-19 pandemic. We also share ways that the patient community can be empowered to provide their voices to decision-making on both COVID-19 treatment protocols and prescriptions of antibiotics.

Antimicrobial resistance and COVID-19: Intersections and implications

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.

Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis

Background

The proportion of patients infected with SARS-CoV-2 that are prescribed antibiotics is uncertain, and may contribute to patient harm and global antibiotic resistance.

Objective

The aim was to estimate the prevalence and associated factors of antibiotic prescribing in patients with COVID-19.

Data Sources

We searched MEDLINE, OVID Epub and EMBASE for published literature on human subjects in English up to June 9 2020.

Study Eligibility Criteria

We included randomized controlled trials; cohort studies; case series with ≥10 patients; and experimental or observational design that evaluated antibiotic prescribing.

Participants

The study participants were patients with laboratory-confirmed SARS-CoV-2 infection, across all healthcare settings (hospital and community) and age groups (paediatric and adult).

Methods

The main outcome of interest was proportion of COVID-19 patients prescribed an antibiotic, stratified by geographical region, severity of illness and age. We pooled proportion data using random effects meta-analysis.

Results

We screened 7469 studies, from which 154 were included in the final analysis. Antibiotic data were available from 30 623 patients. The prevalence of antibiotic prescribing was 74.6% (95% CI 68.3–80.0%). On univariable meta-regression, antibiotic prescribing was lower in children (prescribing prevalence odds ratio (OR) 0.10, 95% CI 0.03–0.33) compared with adults. Antibiotic prescribing was higher with increasing patient age (OR 1.45 per 10 year increase, 95% CI 1.18–1.77) and higher with increasing proportion of patients requiring mechanical ventilation (OR 1.33 per 10% increase, 95% CI 1.15–1.54). Estimated bacterial co-infection was 8.6% (95% CI 4.7–15.2%) from 31 studies.

Conclusions

Three-quarters of patients with COVID-19 receive antibiotics, prescribing is significantly higher than the estimated prevalence of bacterial co-infection. Unnecessary antibiotic use is likely to be high in patients with COVID-19.

Antibiotic Consumption and Stewardship at a Hospital outside of an Early Coronavirus Disease 2019 Epicenter

There are scant data on the impact of coronavirus disease 2019 (COVID-19) on hospital antibiotic consumption, and no data from outside epicenters. At our nonepicenter hospital, antibiotic days of therapy (DOT) and bed days of care (BDOC) were reduced by 151.5/month and 285/month, respectively, for March to June 2020 compared to 2018-2019 (P = 0.001 and P < 0.001). DOT per 1,000 BDOC was increased (8.1/month; P = 0.001). COVID-19 will impact antibiotic consumption, stewardship, and resistance in ways that will likely differ temporally and by region.

The challenges of estimating the human global burden of disease of antimicrobial resistant bacteria

Estimating the contribution of antimicrobial resistance (AMR) to global mortality and healthcare costs enables evaluation of interventions, informs policy decisions on resource allocation, and drives research priorities. However assembling the high quality, patient-level data required for global estimates is challenging. Capacity for accurate microbiology culture and antimicrobial susceptibility testing is woefully neglected in low and middle-income countries, and further surveillance and research on community antimicrobial usage, bias in blood culture sampling, and the contribution of co-morbidities such as diabetes is essential. International collaboration between governments, policy makers, academics, microbiologists, front-line clinicians, veterinarians, the food and agriculture industry and the public is critical to understand and tackle AMR.

The impact of the COVID-19 pandemic on antimicrobial resistance: a debate

The coronavirus disease 2019 (COVID-19) pandemic is having an enormous impact on public health. Infection with SARS-CoV-2 has become a leading cause of morbidity and mortality in many regions around the world. As many COVID-19 patients are treated with antibiotics, there is concern regarding an associated rise in rates of antimicrobial resistance (AMR). On the other hand, social distancing, isolation and reduced travel may result in decreased spread of AMR. In this issue of JAC-Antimicrobial Resistance, we present a PRO/CON debate on the question of the potential impact of COVID-19 on AMR rates.