The Silent Pandemic

Attempts to Relieve the COVID-19 Pandemic Silently Further Another One 

Written by: Sean Park '25
Edited by: Elizabeth Ding '24

It is quite an understatement to simply note the presence of COVID-19 over the past two years. Not a day goes unnoticed without seeing masks, social distancing guidelines, and sanitization stations. Headlines like “Massive Spike in COVID Cases”, “COVID Cases on the Rise” , and “Not an End in Sight for COVID” have become daily occurrences. Since when did this pandemic begin defining our daily lives? A majority of efforts nowadays seem to be aimed at relieving the COVID-19 pandemic. However, at a certain point, it is important to recognize how much is too much. As noted by Dr. Kai Hensel from the University of Cambridge, “there seems to be only one relevant diagnosis these days: the new virus.” [1]. Now — what about the seemingly non-relevant ones? With efforts solely aimed at relieving the pandemic, it is necessary to ask ourselves, what is being left behind to be dealt with later? Antimicrobial Resistance is most certainly one of those leftovers. In fact, the efforts aimed at relieving the pandemic are furthering another one—a silent one to say the least.

Often referred to as a silent pandemic by experts, Antimicrobial Resistance or AMR is a pandemic that began long prior to COVID-19 that continuously goes unchecked. In fact, in the U.S., there are more than 2.8 million AMR infections that result in over 35,000 deaths each year [3]. AMR, as defined by the World Health Organization, occurs when pathogens (e.g. bacteria, viruses, parasites) “no longer respond to medicines” enabling their further survival and spread. This in turn makes infections or diseases originating from resistant pathogens more difficult to contain and treat [2]. Take Clostridium difficile or C. difficile, a bacterium that causes severe abdominal cramping and diarrhea, as an example. C. difficile gained strong resistance as a result of constant exposure to multiple antibiotics, resulting in the selective pressure to develop resistant strains [4]. As noted with C. difficile, one of the ways AMR emerges is by constant exposure to an antibiotic through inappropriate prescription. AMR has also emerged by two other means: 1) lack of control policy over antibiotics and 2) a halt in the development of new antibiotics [2]. Undeniably, the COVID-19 pandemic has furthered the spread of AMR through the means of all three.

Throughout the pandemic, hospitals found themselves flooded with COVID-19 patients. Out of beds, ventilators, front-line nurses and doctors ended up overwhelmed. Even here in Rhode Island, hospitals are seeing “overcrowding, long waits, more patients leaving without being seen, and a fear that the situation might only get worse.” [5]. Unfortunately, it is the fear and exceptional burdens of the pandemic that caused several health professionals to prescribe patients with antibiotics, even when doctors knew they would be ineffective. A New York Times article interviewed Dr. Teena Chopra, Detroit Medical Center’s director of epidemiology and antimicrobial stewardship, who noted that over 80% of incoming patients received antimicrobial treatments. Despite knowing COVID-19 is a viral illness, Chopra pointed to limited treatment choices as the reason behind this inappropriate prescription. The article also notes how desperation and fear of vulnerability to secondary bacterial infections was also a cause behind inappropriate prescription [6]. By unnecessarily prescribing antibiotics during the pandemic, hospital professionals unnecessarily exposed multiple bacterial species to certain antibiotics. This in turn pressures such species to develop resistant species that will reproduce and multiply as a result of natural selection [7]. Simply stated by the New York Times article:

“For many doctors, the pandemic not only provides lessons about the judicious use of antibiotics, but it also highlights another global health threat that has been playing out in slow motion: the mounting threat of antimicrobial resistance.” [6] 

Paradoxically, despite the inappropriate prescription of antibiotics occurring in hospitals during the pandemic, the National Institutes of Health COVID-19 treatment guidelines explicitly advise against the use of antibiotics in the absence of an indication of bacterial infection [8]. Additionally, the World Health Organization recommended that antibiotic therapy should not be used in patients with mild/moderate COVID-19 unless there is a justifiable reason [9]. However, as aforementioned, antimicrobial treatment was given to patients even in the absence of a bacterial or fungal coinfection. This undeniably highlights the lack of control policy over antibiotics throughout the pandemic. It’s important that there are control policies over the use of antibiotics to ensure that they are not overprescribed—as overprescription is the leading cause of the spread of AMR. Following the pandemic, it is critical that not only doctors but health organizations learn from the pandemic and create more concrete policy over antibiotic use. 

Beyond the hospital, the mounting threat of antimicrobial resistance was also realized within pharmaceutical industries over the course of COVID-19. When it comes to AMR, it is important that new antibiotics are constantly being developed to prevent pathogens from developing resistant populations through constant exposure to the same antibiotic. However, what is meant by new antibiotic? In order for an antibiotic to be considered new, it should have a new, innovative mechanism of targeting a pathogenic species. However, in 2020, the World Health Organization noted that there is a lack of innovation and declining private investment in the development of new antibiotics “undermining efforts to combat drug-resistant infections.” [10]. Of all drug-resistant infections, HIV, tuberculosis, and malaria are the ones hit hardest by the COVID-19 pandemic. Given the international response to COVID-19, the urgency of developing a vaccine against COVID-19 overshadowed the necessity of creating antibiotics that target these drug-resistant infections. In turn, funding on the development of an antibiotic against drug-resistant infections like tuberculosis decreased. Consequently, in 2020, there was a 19% decrease in the number of people treated for drug-resistant tuberculosis specifically [11]. At the same time, such drug-resistant infections are given more time to replicate, spread, and infect. As noted in an Editorial of The Lancet Microbe:

“COVID-19 has overtaken tuberculosis as the leading infectious cause of death, which, among other things, is an ironclad justification for the resources that the pandemic response has attracted.” [11]

As noted in the introduction of this article, it is important to recognize how much is too much. Frankly speaking, it’s too much when mounting efforts not only overshadow but also further another detrimental event. Ironically, efforts aimed at relieving one pandemic furthered the spread of another. Although multiple efforts to address AMR were made one or two years after the initial start of the pandemic, clearly it is not enough to halt the factors that are resulting in the spread of AMR. Future pandemics will have to confront the issue of AMR and develop protocols that reduce the spread of a pathogen with consideration to resistant populations. If not, it is most certainly known that this silent pandemic will not remain silent forever … 
References:

[1] Opinion: Why too much focus on covid-19 could be harming our children [Internet]. University of Cambridge. 2020 [cited 2021Nov20]. Available from: https://www.cam.ac.uk/research/news/opinion-why-too-much-focus-on-covid-19-could-be-harming-our-children

[2] Antimicrobial resistance [Internet]. World Health Organization. World Health Organization; [cited 2021Nov20]. Available from: https://www.who.int/health-topics/antimicrobial-resistance

[3] Biggest threats and Data [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2021 [cited 2021Nov20]. Available from: https://www.cdc.gov/drugresistance/biggest-threats.html#cdiff

[4] Banawas SS. clostridium difficile infections: A global overview of drug sensitivity and resistance mechanisms [Internet]. BioMed research international. Hindawi; 2018 [cited 2021Nov20]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841113/#:~:text=Several%20antimicrobial%20drugs%20such%20as,drugs%20%5B27%2C%2028%5D.

[5] Gagosz A, Amaral B. Hospitals in R.I. are struggling with burnout and staffing issues - and the problems are bigger than covid - The Boston Globe [Internet]. BostonGlobe.com. The Boston Globe; 2021 [cited 2021Nov20]. Available from: https://www.bostonglobe.com/2021/09/24/metro/hospitals-ri-are-struggling-with-burnout-staffing-issues-problems-are-bigger-than-covid/

[6] Jacobs A. Doctors heavily overprescribed antibiotics early in the pandemic [Internet]. The New York Times. The New York Times; 2020 [cited 2021Nov20]. Available from: https://www.nytimes.com/2020/06/04/health/coronavirus-antibiotics-drugs.html

[7] How antibiotic resistance happens [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2021Nov20]. Available from: https://www.cdc.gov/drugresistance/about/how-resistance-happens.html

[8] Coronavirus disease 2019 (COVID-19) treatment guidelines [Internet]. [cited 2021Nov20]. Available from: https://files.covid19treatmentguidelines.nih.gov/guidelines/covid19treatmentguidelines.pdf

[9] Adebisi YA, Jimoh ND, Ogunkola IO, Uwizeyimana T, Olayemi AH, Ukor NA, et al. The use of antibiotics in COVID-19 management: A Rapid Review of national treatment guidelines in 10 African countries [Internet]. Tropical Medicine and Health. BioMed Central; 2021 [cited 2021Nov20]. Available from: https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-021-00344-w

[10] Lack of new antibiotics threatens global efforts to contain drug-resistant infections [Internet]. World Health Organization. World Health Organization; [cited 2021Nov20]. Available from: https://www.who.int/news/item/17-01-2020-lack-of-new-antibiotics-threatens-global-efforts-to-contain-drug-resistant-infections

[11] Is the tuberculosis response another casualty of COVID-19? [Internet]. Define_me. [cited 2021Nov20]. Available from: https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(21)00246-9/fulltext