Antimicrobial Resistance: The Next Big Thing
Jhpiego joins the U.S. Centers for Disease Control and Prevention to study this global threat and encourage antibiotic stewardship.
By Flavia Bianchi and Maryalice Yakutchik
As clinicians worldwide feverishly tended to a relentless onslaught of panicked patients sickened by and dying from an upstart virus, an epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC) was also focused on a quieter, long-brewing crisis.
Fernanda Lessa, a physician and expert at the CDC on antibiotic stewardship—the effort to measure and improve how medicines that fight infections caused by bacteria are prescribed by clinicians and used by patients—was concerned about the COVID-19 pandemic’s amplifying effect on antimicrobial resistance (AMR). Joining her in this concern were Drs. Olivia McGovern and Twisha Patel, also of the CDC.
Clinicians and public health experts alike have worried for decades about the growing threat of AMR, which is driven by many factors, including the overuse of antimicrobials.
Mounting anecdotal evidence and published data indicate that we have lost progress combating AMR since 2020 due, in large part, to the effects of the COVID-19 pandemic. Adding to this body of AMR research is a new study in South America led by the CDC and local partners in Argentina, Brazil and Chile, with technical and programmatic support by Jhpiego.
“Our focus in this partnership is facilitating data collection, analysis and synthesis to contribute to the evidence around the impact of antimicrobial use on AMR,” said Stacie Stender, Jhpiego’s lead global health security expert and a specialist in infectious disease. “We need to look at factors that may lead to AMR, and this requires robust data (ideally in real time!) to inform evidence-based decision-making and action. This project is critical to understanding the global security threat that AMRs currently pose – and that will only increase in future, as we have seen in this project.”
AMR occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines, making infections harder to treat and increasing the risk of disease spread, severe illness and death. Once-treatable illnesses, including pneumonia, tuberculosis and minor infections, can become incurable. A 2019 CDC report indicates that more than 2.8 million antimicrobial-resistant infections occur each year in the United States, and more than 35,000 people die as a result.
Although once confined to health care settings like hospitals, AMR is now a community concern worldwide, says Dr. Lessa, the CDC’s Acting Chief of the International Infection Control Program in the Division of Healthcare Quality Promotion.
“Several publications were showing high use of antibiotics among COVID-19 patients despite low rate of secondary bacterial infections,” Dr. Lessa explains. “However, most data were coming from single-center studies and case series, which prompted the CDC team to reach out to colleagues in Argentina, Chile and Brazil.”
Earlier this year, she initiated a multi-center collaboration across six hospitals in those three South American countries, and Jhpiego joined this investigation of antimicrobial use and resistance pre-and post-onset of the COVID-19 pandemic. Surveillance of AMR is standard practice in hospitals.
Eager to contribute to the study was Dr. Maria Isabel Garzón, an infectious disease specialist with the Epidemiological Surveillance and Infection Control Department at the University Hospital Privado in Córdoba, Argentina. She witnessed the reappearance of a superbug (Carbapenem-resistant Enterobacterales) in a Córdoba hospital after it had been eliminated thanks to rigorous infection prevention and control measures. Intuition told her its reprise was likely linked to providers overprescribing antibiotics during surges of patients sick with COVID-19, symptoms of which are similar to those of bacterial infection.
On the other side of the continent, Dr. Icaro Boszczowski, who heads Infection Control at Hospital Alemão Oswaldo Cruz and also works as at Hospital das Clínicas, in São Paulo, Brazil, was reading reports revealing that although few patients had documented bacterial co-infections with COVID-19, between 50- to 100 percent of patients with COVID-19 were receiving antimicrobials.
Meanwhile, in Chile, teams at Clínica Alemana and Hospital Padre Hurtado also started seeing outbreaks of resistant bacteria. Prior to COVID-19, AMR was not a big concern in private hospitals, says María de los Ángeles Spencer of the Genomic and Resistance Microbes (GeRM) group at the Institute of Science and Innovation in Medicine. Her colleagues’ reports set off an alarm about a potential public health crisis.
Potential drivers of increased antimicrobial-resistant infections during the height of the pandemic include the influx of patients and their severity of illness, the shortage of health care personnel, misuse and overuse of antibiotics, and disruptions to infection prevention and control practices. The impact of these factors on AMR will be assessed as the study continues.
When first-line antibiotics fail as a result of resistance, patients may require second- and third-line treatments that can cause serious side effects, prolonging care and recovery. In some cases, no more treatment options exist.
The clinical pipeline for new antimicrobials is startlingly dry, notes Jhpiego’s Stender, who directs Enhancing Global Health Security, a Jhpiego-led, multi-country global health security project funded through the CDC. “As antibiotics become increasingly ineffective due to the spread of resistance and with no new treatment options in the immediate future, AMR becomes an increasingly complex public health threat requiring urgent action,” she says.
AMR, like COVID-19, knows no borders, making worldwide stewardship of antibiotics an imperative. However, many places have difficulty relating to data collected in the U.S., and adhering to guidelines established here, explains Dr. Lessa. Recognizing that there is no one-size-fits-all approach to optimize antibiotic use for all settings, the CDC aims for this context-specific study across South America to allow countries there to mount more effective local and regional responses, and to strengthen infection prevention and control and antimicrobial stewardship programs.
“The ultimate goal,” Dr. Lessa says, “is for countries to be able to learn from this unprecedented COVID-19 pandemic and its impact on antimicrobial use and resistance in order to be better prepared for future public health emergencies and avoid reverting any progress towards combating antimicrobial resistance globally.”
Flavia Bianchi is a senior technical advisor, Monitoring and Evaluation, at Jhpiego. Maryalice Yakutchik is a senior writer for Jhpiego.
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Illustrations by OpenAI