United Against Drug Resistance: From threats and opportunities from COVID-19, to action against AMR

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World Antimicrobial Awareness Week 2020

For the sixth year in a row, the World Health Organisation is spearheading the Antimicrobial Awareness Week campaign, which aims to highlight the growing threat of drug resistance worldwide. The slogan for this year is: “Antimicrobials: handle with care.”

Emerging evidence suggests that COVID-19 patients are often treated with antibiotics in hospital, even where no bacterial infection is present. This can increase drug resistance. However, research also suggests that better hygiene and infection control have in some cases reduced infections and disease transmission.

These points were discussed during the Fleming Fund’s annual Delivery Partners meeting in October. Dame Sally Davies, the UK’s Special Envoy for AMR, chaired a panel discussion on threats and opportunities from COVID-19. Panellists included:

• Mirfin Mpundu, Director, ReACT Africa
• Dr Hanan Balkhy, Assistant Director General for AMR, WHO
• Dr Keith Sumption, Chief Veterinary Officer, FAO
• Dr Charles Mwansambo, Permanent Secretary, Malawi Ministry of Health

Dame Sally: What evidence links antimicrobial resistance (AMR) and COVID-19? What gaps do we have in our knowledge?

Mirfin: Many studies show that COVID-19 patients are treated with antibiotics, even in the absence of bacterial infections. For example, in one study in China, 58% of the COVID-19 patients studied were administered antibiotics without any diagnostic testing data to back up treatment.

There are also similar challenges between AMR and COVID-19 from the clinical and systems perspective. These include a high morbidity rate, expensive treatment, the overarching threat they pose to society and the likelihood that both issues will push people into poverty.

Dame Sally: Is there a danger that AMR resources are being drained by the COVID-19 response?

Hanan: I think resources are being repurposed – this happened with H1N1 and it happened with Swine Flu. That’s why we need a mindset change to develop an integrated and holistic pandemic and AMR response. For example, infection prevention and control, stewardship of agents (including antimicrobials) and leadership are important for both AMR and COVID-19 responses.

Dame Sally: Will greater attention on global health security have implications for AMR? What about One Health?

Keith: Governments are increasingly interested to understand the drivers behind pandemics. And part of that is understanding the role of animal infections and animal health systems. We are concerned that the current focus on zoonotic pandemics (diseases that jump from animals to humans and vice versa) may detract attention from non-zoonotic epidemics in animals. In many cases, it is the latter that drive heavy national (animal) antimicrobial use. We also need vaccines at every level. So many animal infections are preventable if vaccines are available. However, in some cases it seems COVID-19 has caused a reduction in national (animal) vaccination programmes.

Additional Questions: Could we see a reduction in AMR from changes in societal behaviour (e.g. isolation, quarantine, infection control) or the disruption of healthcare?

Charles: We are hoping infection control and handwashing measures will reduce disease and bacteria transmission. However, if healthcare is disrupted people tend to seek treatment in other “sub-optimal” locations where they are more likely to receive substandard medication (which can increase resistance).

Mirfin: I’ve been hearing from doctors in Kenya and Zambia that they’ve seen a reduction of diarrheal cases in hospital. This is really encouraging because we’ve seen infection control interventions are really making a difference. However, it’s important for us to pause and ask how we can sustain these activities over the long term. As we’ve seen with Ebola, public handwashing and infection prevention activities are only sustainable while we have a threat.

Additional Questions: How can we leverage attention from COVID-19 to improve clinical engagement and diagnostics?

Mirfin: We need to teach and train people to conduct tests. We don’t want a repeat of some of the things we saw with malaria, where regardless of whether a malaria test was positive or negative patients received antimalarial treatments.

Hanan: AMR isn’t like any other disease – there’s no silver bullet. The reason for that is that bacteria keep changing so we need to keep up with science. Although the solution to AMR is a comprehensive one, the laboratory component is critical. We need to keep the prescribers knowledgeable about what they are doing.

Charles: We need to ensure we don’t work in isolation. We’ve been slow on diagnostics. For example, right now there is a huge push in the COVID-19 response to develop a vaccine, but it’s likely that the response may just as quickly shift to developing better diagnostics. Both components are important, and we need to be on top of these trends.

This interview has been edited and condensed for clarity.