Antibiotic resistance during and beyond COVID-19.

David M Livermore

doi:10.1093/jacamr/dlab052

Abstract

Antibiotics underpin the ‘modern medicine’ that has increased life expectancy, leading to societies with sizeable vulnerable elderly populations who have suffered disproportionately during the current COVID-19 pandemic. Governments have responded by shuttering economies, limiting social interactions and refocusing healthcare. There are implications for antibiotic resistance both during and after these events. During spring 2020, COVID-19-stressed ICUs relaxed stewardship, perhaps promoting resistance. Counterpoised to this, more citizens died at home and total hospital antibiotic use declined, reducing selection pressure. Restricted travel and social distancing potentially reduced community import and transmission of resistant bacteria, though hard data are lacking. The future depends on the vaccines now being deployed. Unequivocal vaccine success should allow a swift return to normality. Vaccine failure followed by extended and successful non-pharmaceutical suppression may lead to the same point, but only after some delay, and with indefinite travel restrictions; sustainability is doubtful. Alternatively, failure of vaccines and control measures may prompt acceptance that we must live with the virus, as in the prolonged 1889–94 ‘influenza’ (or coronavirus OC43) pandemic. Vaccine failure scenarios, particularly those accepting ‘learning to live with the virus’, favour increased outpatient management of non-COVID-19 infections using oral and long t½ antibiotics. Ultimately, all models—except those envisaging societal collapse—suggest that COVID-19 will be controlled and that hospitals will revert to pre-2020 patterns with a large backlog of non-COVID-19 patients awaiting treatment. Clearing this will increase workloads, stresses, nosocomial infections, antibiotic use and resistance. New antibiotics, including cefiderocol, are part of the answer. The prescribing information for cefiderocol is available at: https://shionogi-eu-content.com/gb/fetcroja/pi.

Highlights

The modern medical era began around 1937-42, as systemic sulphonamides and penicillin mitigated the hazard of bacterial infection, opening medical and surgical possibilities that were previously unthinkable.Antibiotics remain the bedrock of what followed: complex surgery, intensive care, transplants and immunosuppressive treatments would be impossible if infection could not be controlled
Across 5 UK ICUs we found Klebsiella pneumoniae and K. aerogenes unusually prevalent in COVID-19 patients,[32] whereas a single-hospital French study found an excess of non-fermenters.[33]
The aim here, following vaccine disappointments, would be to suppress COVID-19 sufficiently that normality of a sort resumes within a closed system, as presently in Taiwan, Australia or New Zealand, all of which achieved early control of viral spread meaning that their hospitals are not under the pressures outlined above

Summary

Introduction

The modern medical era began around 1937-42, as systemic sulphonamides and penicillin mitigated the hazard of bacterial infection, opening medical and surgical possibilities that were previously unthinkable.Antibiotics remain the bedrock of what followed: complex surgery, intensive care, transplants and immunosuppressive treatments would be impossible if infection could not be controlled. Population had been infected,[14] and that deaths attributed to COVID-19 had reached 1 million. Most non-hospitalised COVID-19 patients receive no antibiotics.

Results

Conclusion