COVID-19 and AMR – what do we know so far?

2020-04-02

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a new coronavirus that was only recently discovered in 2019. The virus causes the COVID-19 pandemic which currently requires the full focus, commitment and support from all governments, international institutions and organizations, the healthcare workforce, the private sector, civil society and the general public.

Some attention has started to be given to the role of secondary infections as well as antibiotic resistance in patients with COVID-19. Currently, however, too little information is available to draw any full conclusions on the potential impact antibiotic resistance might have on COVID-19 outcomes.

ReAct is however, carefully monitoring the field and is assessing the data that is emerging and intersect with antibiotic resistance. Here we try to provide an overview of what is known so far about how AMR and COVID-19 relate.

Bacteria or viruses – what is the difference?

Although bacteria and viruses both are known to be disease-causing agents, they are fundamentally different. Bacteria are single-celled organisms that are found all around us – including in and on our bodies. There is a huge variety of bacterial species and they have important roles to play in all kinds of ecosystems. Antibiotics can be used to treat bacterial infections, but only a fraction of bacteria actually cause disease.

Viruses, on the other hand, are not made up of cells. They are composed of genetic material – DNA or RNA – that is covered by a coat of protein. Unlike bacteria, viruses lack ability to reproduce independently and therefore need to enter cells of other host organisms to be able to multiply. As such they are always parasitic, regardless of the host being a human, an animal, a plant or a bacterium. The virus causing COVID-19 spreads through respiratory droplets, primarily when an infected person coughs or sneezes.

Viral infections, COVID-19 included, cannot be treated with antibiotics. However, some viral infections may damage our cells so badly that it becomes easier for certain bacteria to cause so-called secondary infections. A fairly common example is bacterial pneumonia in influenza patients, which can be treated with antibiotics.

Secondary infections in COVID-19 patients

A recently published Lancet study looked at 191 hospitalized adult patients in Wuhan, China, that had been diagnosed with COVID-19 and either had died or had been discharged at the end of January this year. Although the sample size was quite small, the researchers found that half of the patients who died (n=27/54) also had a secondary infection, and that all but one of them had been treated with antibiotics. This has been picked up by media around the world and has initiated a relevant discussion about the potential impact of antibiotic resistance on the outcomes of COVID-19 patients. At the center of thought is that countries with higher burden of antibiotic resistance might be worse off if secondary bacterial infections are a common complication.

However, it is worth noting that the secondary infections affecting the dying, hospitalized patients in Wuhan happened at a very late stage of the disease (median time was 17 days after the illness first began). The patients generally faced severe symptoms like sepsis and acute injuries to the heart and kidneys earlier (median time to onset in non-survivors was 10, 14.5 and 15 days, respectively). Sepsis – which often might have been caused by the SARS-CoV-2 virus itself – occurred in 100% of the patients who did not survive, whereas acute heart and kidney injuries happened to 59% and 50% of them, respectively.

So far it remains unclear whether the antibiotics did not work due to resistance, or whether the patients were so weak when they contracted the secondary infections, that death was inevitable. More and larger studies from different countries will be needed to shed more light on these issues. It will be important for the world’s response both in the more immediate term – and for long-term preventive actions – to understand what role secondary bacterial infections and antibiotic resistance might play in the current pandemic.

Hand washing – effective for infection prevention

Two girls at a school in Kenya showing their friends how to wash your hands. For World Antibiotic Awareness Week 2019, a collaboration with ReAct Africa. Footage: ReAct Africa.

A number of events in medical history have had an extraordinary impact on public health. One of them is the discovery and use of antibiotics and vaccines, another is the realization that improved sanitation and hygiene – such as hand washing – reduces the spread of infectious diseases. With the COVID-19 pandemic, the simple message of hand washing has made it to the top of the agenda and is getting the attention it deserves as the effective infection control measure that it is.

The R&D response to COVID-19 opens up for new approaches

The research and development (R&D) field in relation to COVID-19 is currently developing fast with many actors trying their best to advance promising vaccine candidates, develop new treatments and diagnostics, and testing repurposed existing drugs. The WHO has for example initiated a global mega trial of four different existing drugs with simplified procedures to make it as easy as possible for hospitals in countries to participate and report data. Other interesting proposals put forward include a request from Costa Rica to the WHO to establish a voluntary intellectual property pool for all COVID-19 relevant technologies which the WHO is now in the process of assessing. The public private vaccine development initiative CEPI published a piece in the New England Journal of Medicine where they made a call for:

“a global financing system that supports end-to-end development and large-scale manufacturing and deployment, ensures fair allocation, and protects private-sector partners from significant financial losses will be a critical component of future pandemic preparedness”.

In late March an editorial from The Financial Times came out endorsing countries’ use of the TRIPS enshrined right to issue compulsory licenses and thereby remove patent protection for drugs and health technologies where it is deemed an obstacle to protecting public health. Countries such Germany, Canada, Australia and Chile are now reportedly taking steps or are considering changing their national intellectual property legislation to more easily allow the issuing of compulsory licenses. Such proposals have previously been very difficult to advance and the few LMIC’s that have issued or simply just considered issuing compulsory licenses have faced strong political repercussions from HICs. These developments are interesting as they will likely be useful trailblazers for solutions that could also solve the antibiotic R&D crisis by allowing alternative approaches to emerge and be tested.

Will there be more antibiotic shortages?

Even before the spread of COVID-19, the problem of shortages of essential medicines has been an increasing concern in many countries. Although solid data has not yet emerged to indicate further disruptions in supply, it is likely that this pandemic will be a compounding factor on the problem given that key producing countries like China and India have been affected by lockdown. The development of the supply situation should be monitored closely over the coming months as the pandemic’s effect on production capacity and the functioning of supply chains may only become visible when current stocks in countries start to run out. A mapping of what medicines are most likely to be in shortage would be helpful to allow contingency plans to be developed in particular if antibiotics on the essential medicines list are at risk of being in shortage.

Further reading

ReAct article: Shortages and AMR – why should we care? 4 consequences of antibiotic shortages

Antibiotic Resistance Coalition article: COVID-19’s implications for global health and AMR.

COVID-19 Resource Guide: To help colleagues’ friends and families through these difficult times.