The monkeypox outbreak: Need for antibiotic stewardship?

2022-09-29

On 23 July this year, the World Health Organization (WHO) declared that the monkeypox outbreak spreading globally is a "public health emergency of international concern" (PHEIC), the agency’s highest alarm. Monkeypox is a viral zoonosis (it originated in animals and jumped to infect human) that causes flu-like symptoms and a blistery rash that lasts two to four weeks. A vast majority of those infected recover without severe illness, although a small percentage develop sepsis or other severe secondary infections.

The monkeypox virus has been previously recorded in Central and West Africa, yet in the last few months small outbreaks have been reported in several countries, including Europe and the Americas. As of 22nd September 2022, there were 64,916 cases worldwide and 64,336 in locations that have not historically reported monkeypox, with 26 deaths reported (US CDC).

Hot on the heels of the deadly COVID-19 pandemic, the concern of monkeypox becoming a pandemic has garnered worldwide attention. Notwithstanding, while monkeypox has some general common traits with the COVID-19 infection (e.g., both are viral zoonosis that can spread from human-to-human), worries about it becoming a global pandemic of similar proportions do not have any solid basis, as of today.

Few substantial differences between monkeypox and COVID-19

• Fatality rate: Unlike the circulating strains of COVID-19, the monkeypox virus is much less contagious and with a much lower case fatality rate (Grant et al., 2022; Rajgor et al., 2020). Also, except few cases of severe complications, most of those infected by monkeypox virus recover within a few weeks without the need for treatment.
• Transmission: Unlike COVID-19 and influenza which are respiratory viruses, monkeypox spreads via person-to-person contact, including direct contact with body fluids or wounds. Respiratory transmission may occur when people have close face-to-face contact.
• Vaccines: While in the case of COVID-19 it took over a year to find a suitable vaccine to prevent infection, in the case of monkeypox a vaccine is already available (US CDC), although the issue of equitable access in low- and middle-income countries (LMICs) still remain unresolved.

Implications of monkeypox for antibiotics consumption: what can we expect?

Although antibiotic therapy or prophylaxis should not be used in patients with uncomplicated viral infections, incorrect diagnosis and/or treatments, as well as self-medication, can increase antibiotics consumption even during viral outbreaks. For example, during the early phase of the COVID-19 pandemic, a study reported that 8501 out of 10,329 patients (82.3%), were prescribed antibiotics independent of the severity of the COVID-19 infection (Cong et al., 2021). The clinically unjustified use of antibiotics, mostly due to lack of knowledge and concern for the pandemic outbreak, can expose patients to an accelerated development of resistant bacteria. Considering the recent incidence of the monkeypox outbreaks in Europe, a similar increase in antibiotic consumption, as the one occurred in the initial stage of the COVID-19 pandemic, could be expected.

Antibiotic use and monkeypox – preliminary data

Only a few weeks after the first European registered case of monkeypox, a few studies already reported associated bacterial super-infections requiring intense antibiotic treatments (Girometti et al., 2022; Moschese et al., 2022; Ortiz-Martínez et al., 2022). Besides the justified increase of antibiotics use due to monkeypox-associated bacterial infections, second- and third-generation antibiotics have been previously used as prophylactic and/or empiric therapy on monkeypox patients (Reynolds et al., 2017), potentially exacerbating the antibiotic resistance issue. Not least, a recent investigation on Jordanian Health Schools, revealed that 48% of students believe that monkeypox should be treated with antibiotics (about 41% did not know, and only 11% answered correctly). The latter is of particular concern, especially in countries where self-medication and over-the-counter selling of antibiotics occur.

Do’s and don’ts

At this juncture, although the world finds itself facing another viral outbreak, this should not result in more unnecessary use of antibiotics. Instead, the principles of antibiotic stewardship should be strictly followed, as they also aid in preventing viral infections.

Some of the other do’s and don’ts that are useful to keep in focus include

• Follow trustworthy science-based guidelines, e.g. WHO, 2022, strongly discouraging the empiric or prophylactic use of antibiotics.
• Follow general infection prevention control measures (e.g., WASH – water, sanitation and hygiene), that can also be essential to prevent secondary infections, like sepsis, among monkeypox patients.
• Ensure adequately trained personnel to prevent monkeypox and provide appropriate treatment where necessary.
• Do not stigmatise those affected by monkeypox (or any other illness).