Antimicrobial resistance (AMR) has been identified by experts as a pitfall that may arise from the ‘new normal’ of the COVID-19 pandemic with virtual assessments limiting diagnostic capabilities.
In India, poor availability and utilisation of diagnostics have led to increased focus on AMR and the need for better stewardship. Agencies such as the World Health Organization (WHO) have, as a result, taken steps to limit overreliance on and overuse of antimicrobials in both community and hospital settings.
The WHO has identified concerns that AMR will be further fuelled by the inappropriate use of antibiotics during the COVID-19 pandemic, pointing out how individuals who have a mild disease without pneumonia or moderate disease with pneumonia receive antibiotics. As such, the WHO has issued guidance specifically to not provide antibiotic therapy or prophylaxis to patients with mild COVID-19 or to patients with suspected or confirmed moderate COVID-19 illness unless there is a clinical indication to do so.
COVID-19 patients who misuse or overuse antibiotics are often prescribed based on clinical presentation rather than laboratory markers. Even discounting the ‘new normal’ landscape, differentiation between bacterial and viral pneumonia can be difficult even with availability of laboratory tests.
With the ‘new normal’ and the likelihood virtual patient assessments may continue for the foreseeable future, AMR’s threat is increased. Speaking about the situation, Dr G. S. Vijayakrishnan, state secretary of the Kerala Government Medical Officers’ Association, said “considering the pandemic situation, telemedicine is being used for a limited time. The most effective way is personally examining a patient to understand the real condition.”
Antimicrobial stewardship integration
Whilst antimicrobial stewardship ultimately remains part of a wider plan involving early diagnosis of AMR with advancements in technology, AMR stewardship provides guidelines to effectively reduce the threat of AMR. This is especially important in the age of COVID-19. AMR stewardship is defined by the Pediatric Infectious Disease Society as
“Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration.”
For AMR stewardship to be effective as it relates to COVID-19 treatment, it is key for countries such as India to introduce guidelines to define indications and conditions of antibiotic use in COVID-19 patients and encourage treatment providers to follow the principles of antimicrobial stewardship.
Key to the development and dissemination of these evidence-based guidelines are physicians and microbiologists who initiate stewardship measures as well as in framing infectious disease treatment guidelines.
Ultimately, stewardship in the fight against AMR is inclusive of diagnostic stewardship; clinical stewardship; infection control stewardship; environment and sanitation stewardship; and administrative and leadership stewardship. Collectively, guidelines and awareness are hoped to reduce misuse and overuse of antibiotics, especially in light of COVID-19.
The NAP-AMR introduction
The backdrop to the challenge posed by COVID-19 also includes the National Action Plan for Antimicrobial Resistance (NAP-AMR) which was rolled out across India over three years ago.
The plan’s objectives are to improve awareness, enhance surveillance measures, and strengthen infection prevention and control amongst other measures. However, to date, only three states – Delhi, Kerala, and Madhya Pradesh – have come out with their state action plan, with others at various stages of development.
Speaking about the challenge posed by COVID-19, a microbiologist at a government hospital, said “the risk of over-prescribing can’t be overlooked. The same is the case with COVID-19 patients receiving antibiotics. It is high time that the officers overseeing the Kerala AMR Strategic Action Plan should consider this and come up with remedial measures.”