Hong Kong Med J 2021 Dec;27(6):396–8 | Epub 17 Nov 2021
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
EDITORIAL
Combating antimicrobial resistance during the
COVID-19 pandemic
Edmond SK Ma, FHKAM (Community Medicine)1,2; KH Kung, MMedSc, FHKAM (Community Medicine)2; Hong Chen, MPH, FHKAM (Community Medicine)2
1 Epidemiology Adviser, Hong Kong Medical Journal
2 Infection Control Branch, Centre for Health Protection, Department of Health, Hong Kong SAR Government, Hong Kong
Corresponding author: Dr Edmond SK Ma (edmond_sk_ma@dh.gov.hk)
Global attention has been drawn to combat
coronavirus disease 2019 (COVID-19), draining
tremendous government resources, political
commitment, public health measures, manpower of
healthcare professionals, media, and public interest.
The COVID-19 has also seriously affected the global
effort against antimicrobial resistance (AMR).
According to a survey conducted in late 2020 by
the World Health Organization (WHO) AMR
Surveillance and Quality Assessment Collaborating
Centres Network, 63% (35 out of 56 countries)
reported an increase in total prescriptions of
antibiotics, with 47% (23/49), 57% (27/47), and 40%
(18/45) of countries reporting increased use of WHO
Access, Watch, and Reserve antibiotics, respectively.1
More importantly, 37% (13/35) and 40% (12/30)
of countries reported an increase in multidrug-resistant
organism (MDRO) healthcare-associated
infections and MDRO infections in long-term care
facilities, respectively. Outbreaks and increases in
AMR acquisition, such as carbapenemase-producing
Enterobacteriaceae, have also been reported by
hospitals during the COVID-19 pandemic.2 3 4
The situation of MDRO in Hong Kong is
worrisome. The Hospital Authority has reported a
higher rate of methicillin-resistant Staphylococcus
aureus bacteraemia detected after 48 hours of
admission in 2020 and the first half of 2021, compared
with that of previous years, although this may be
due to a reduction in hospital admission of milder
cases.5 An outbreak of Candida auris, an often
highly resistant emerging infection, during the third
wave of the COVID-19 pandemic is also concerning.
From 29 June 2020 to 9 October 2020, the Hospital
Authority reported 41 patients with Candida auris
colonisation to the Infection Control Branch of the
Centre for Health Protection for infection control
advice after discharge to residential care homes.6
The number of cases of carbapenem-resistant
Enterobacteriaceae discharged to residential care
homes for the elderly rose from 242 cases in 2019
to 259 cases in 2020, and then sharply to 329 cases
between January and August 2021.
The COVID-19 pandemic has affected
antimicrobial stewardship activities and driven AMR in various ways. Drifting of resources,
including laboratory capacity, reduced reagents and
consumables, physician and nursing manpower,
and public health staff, have undermined
antimicrobial stewardship programmes in many
countries. Weakened infection control due to
fatigue and heavy workload of healthcare workers,
and shortages of personal protective equipment in
the early days of the pandemic further aggravated
the problem. Hospital admission may increase
the risk of healthcare-associated infections and
the transmission of MDROs, which in turn may
lead to increased antimicrobial use. Disruption to
routine immunisation activities, due to COVID-19-related measures, has led to reductions in overall
vaccination coverage globally, potentially leading to
an overuse of antimicrobials.7 8 9 Low-level exposure
to biocidal agents can strengthen drug-resistant
strains and enhance the risk of cross resistance
to antibiotics, particularly those that treat Gram-negative
bacteria.10
Another important impact of COVID-19 on
increasing AMR is secondary bacterial infection
among patients with COVID-19. Empirical treatment
of patients with COVID-19 using antibiotics is
common. A meta-analysis involving 154 studies and
over 30 000 patients revealed that 74.6% of patients
with COVID-19 received antibiotics, significantly
higher than the estimated prevalence of bacterial
co-infection.11 This is echoed by another review
of studies published on hospitalised patients with
COVID-19, which revealed 72% (1450/2010) of
patients received antibiotics but only 8% (62/806)
had bacterial or fungal co-infections.12 The most
common type of secondary infection of COVID-19
was pneumonia (especially ventilator-associated
pneumonia), followed by bloodstream and urinary
tract infections, and the most commonly used
agents included fluoroquinolones, cephalosporins,
carbapenems, azithromycin, vancomycin,
and linezolid.13 14 Those with complications of
COVID-19 may require mechanical ventilation or
other invasive devices, which increases the risk of
acquiring hospital-associated pathogens that are
often highly resistant, such as methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa,
and Acinetobacter baumannii.15
Despite the challenges posed to AMR,
the COVID-19 pandemic also creates some
opportunities, such as enhanced infection control
measures among healthcare workers and the high
alertness of personal hygiene among the general
public. These measures, which include cough
etiquette, hand hygiene, wearing of masks, and
social distancing, have helped to reduce various
infections, in particular those caused by respiratory
pathogens.16 17 18 In addition, increased fear of
attending healthcare facilities and postponement
of elective hospital procedures have resulted
in fewer medical consultations and antibiotic
prescriptions. Surveillance data on wholesale
antimicrobial consumption in Hong Kong show
a substantial reduction (28.3%) in daily defined
doses of antimicrobials from 19.02 million in 2019
to 13.63 million in 2020. In particular, there were
major reductions (of between 35.3% and 51.5%)
in wholesale supply to general practitioners of
amoxicillin with or without beta-lactamase inhibitor,
azithromycin, and cefuroxime, which are commonly
prescribed to manage upper and lower respiratory
tract infections. In Hong Kong, social distancing
measures imposed by public health authorities,
school and kindergarten closures, work-from-home
policies, other restrictions involving catering
businesses and scheduled premises such as fitness
centres, beauty salons, karaoke establishments and
sport centres, have all helped limit transmission
through the respiratory route and person-to-person
contact of not only COVID-19 but also other
infections. Enhanced environmental hygiene using
diluted household bleach containing 5.25% sodium
hypochlorite can kill severe acute respiratory
syndrome coronavirus 2 and other pathogens
including MDROs.
Although more research is needed to dissect
the intermingled relationship between COVID-19
and AMR, it is of utmost importance to maintain
efforts against AMR. The theme for World Antibiotic
Awareness Week, held on 18 to 24 November
2021, was “Spread Awareness, Stop Resistance”. The
dedicated page on the Centre for Health Protection
website (https://www.chp.gov.hk/en/features/47850.
html) includes access to the latest IMPACT
(Interhospital Multi-disciplinary Programme
on Antimicrobial ChemoTherapy) guideline, an
evidence-based clinical guideline to ensure that
patients receive the right antibiotic, at the right
dose, at the right time, and for the right duration that
leads to the best clinical outcome for the treatment
or prevention of infection while producing low risk
for subsequent resistance. The website also allows
access to patient education and publicity materials
on AMR. Similar to COVID-19, AMR is a complex global priority and everyone has a role to play.
Author contributions
All authors contributed to the editorial, approved the final version for publication, and take responsibility for its accuracy and integrity.
Conflicts of interest
The authors have declared no conflict of interest.
Funding/support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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