On The Cover
Loren Bonner
This summer, Daniel P. McQuillen, MD, president of the Infectious Diseases Society of America, said that with rates of antimicrobial-resistant infections rising quickly, systemic changes are urgently needed to protect public health.
“This is no longer a future crisis, but one that is at America’s doorstep and needs to be addressed now,” he said. “Whenever there are high levels of hospitalizations, rates of antimicrobial-resistant infections and deaths will likely further increase unless we take steps to prevent them.”
According to CDC, the pandemic has undone much of the nation’s progress on antimicrobial resistance, especially in hospitals. In a new 2022 special report, CDC finds that antimicrobial-resistant infections and deaths rose 15% in 2020 due to the COVID-19 pandemic. Antimicrobial resistance is quickly becoming a pandemic itself, and the COVID-19 pandemic is only expediting this.
CDC also reported that, after years of steady reductions in health care–associated infections, U.S. hospitals saw significantly higher rates for 4 out of 6 types of health care–associated infections in 2020. Many of these are resistant to antibiotics or antifungals. CDC identified substantial increases in infections across carbapenem-resistant Acinetobacter, extended-spectrum β-lactamase-producing Enterobacterales, vancomycin-resistant Enterococcus, drug-resistant Candida auris, and many other health care–associated pathogens.
“[The report] details slowed progress and deleterious effects related to antimicrobial resistance as a result of increased antibiotic use, decreased infection prevention and control strategies, and reductions in detection and reporting of antimicrobial resistance,” said Barbara Santevecchi, PharmD, BCPS, clinical assistant professor at the University of Florida College of Pharmacy.
CDC noted in the report that during the pandemic, “the detection and reporting of antimicrobial resistance data slowed tremendously because of changes in patient care, lab supply challenges, testing, treatment, and the bandwidth of health care facilities and health departments.” In some instances, public health resources were forced to shift from tracking antimicrobial resistance to tracking COVID-19 cases.
“Much of the data from 2020 are unavailable or delayed, and the data that we do have show marked increases in resistance among many serious pathogens,” said Kerry LaPlante, PharmD, FCCP, professor and chair of pharmacy practice at the University of Rhode Island and director of the Rhode Island Infectious Diseases Research Program and Infectious Diseases Pharmacotherapy. “We don’t fully know how bad the damage is.”
The PASTEUR Act
Nikunj Vyas, PharmD, BCPS, said we are living in a postantibiotic era, and he worries most about not having effective antibiotic options to treat patients.
“The thing I lose sleep over is the fact that we will reach a point where we have very limited to no effective treatment options to treat these patients with multidrug-resistant organisms,” said Vyas, who is a clinical pharmacy specialist in infectious diseases currently practicing at Jefferson Health New Jersey. “The bacteria will always be a step ahead of us. We will need newer agents along with effective antimicrobial stewardship in a rapid way.”
According to WHO, antimicrobial resistance is among the top 10 global public health threats. “To add to this concern, the antimicrobial development pipeline is not suited to meet demands posed by antimicrobial resistance,” said Barbara Santevecchi, PharmD, BCPS, clinical assistant professor at the University of Florida College of Pharmacy. “Without additional efforts dedicated to judicious use of the antimicrobials we have and development of novel agents, we will undoubtedly find ourselves in a situation without effective antimicrobials to treat infections.”
The Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act was introduced in the U.S. Senate and House of Representatives in June 2022 and aims to promote increased development of novel antimicrobials as well as provide support for hospital antimicrobial stewardship programs.
Visit idsociety.quorum.us/campaign/33927/ to learn more about the PASTEUR Act.
Antimicrobial stewardship takes back seat at hospitals
Antimicrobial resistance occurs when bacteria and viruses evolve, in turn making the drugs used to kill their infection less effective or entirely ineffective. The main cause of antimicrobial drug resistance is excessive and inappropriate use of antimicrobial drugs. This is where antimicrobial stewardship comes in. But during the pandemic, many of these efforts were put on the back burner.
“Antimicrobial stewardship became less of a priority during 2020 because resources were shifted toward fighting the COVID-19 pandemic,” said LaPlante. “This, in combination with an overwhelmed health care system, created a perfect storm to expedite resistance development among the population.”
Nikunj Vyas, PharmD, BCPS, a clinical pharmacist in infectious diseases currently practicing at Jefferson Health New Jersey who leads antimicrobial stewardship efforts at his hospital, said one of the biggest challenges to stewardship efforts during the pandemic was resources.
“You have dedicated personnel for these activities, but when the pandemic hit, we ended up having to split those resources with COVID care,” said Vyas, who oversees infectious disease pharmacotherapy at Jefferson Health New Jersey. “Your day-to-day antimicrobial stewardship activities take a hit.”
Santevecchi, who is also a clinical specialist in infectious diseases at UF Health Shands Hospital, said she also saw this first-hand in her own practice, in which they dedicated at least one full-time infectious disease pharmacist to support COVID-19 efforts on a daily basis.
“In the beginning of the pandemic, many institutional antimicrobial stewardship programs shifted away from the day-to-day stewardship activities and toward multifaceted management of the COVID-19 pandemic,” Santevecchi said. “This occurred naturally as stewardship programs were well suited to manage access to novel COVID-19 therapeutics and development of institutional guidelines, especially in resource-limited settings.”
The diagnostic aspect of antimicrobial stewardship also suffered, Vyas said. “With COVID there was so much uncertainty at first, so we couldn’t perform optimally. Younger patients were coming in and we wanted to make sure we were covering our bases due to high severity of illness.”
Oftentimes, that meant giving antibiotics. From March 2020 to October 2020, CDC found that almost 80% of patients hospitalized with COVID-19 received an antibiotic. Antibiotic use was lower overall as of August 2021 compared to 2019 but increased for some antibiotics like azithromycin and ceftriaxone. Approximately half of hospitalized patients received ceftriaxone, which was commonly prescribed with azithromycin according to CDC.
They noted in the report that this likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital for assessment.
In some instances, COVID-19 therapies are also immunosuppressive and can put patients, who may otherwise be able to fight off infection, at a higher risk for bacterial or fungal infections that are acquired during hospitalization.
Moreover, there were longer hospital stays for many COVID-19 patients. “With prolonged stays, patients are at higher risk for hospital-acquired infections and they may need broad-spectrum antibiotics,” Vyas said.
CDC said there were more patients who were sicker during the pandemic.
These patients required more frequent and longer use of catheters and ventilators, which may have increased the risk of health care–acquired infections and the spread of pathogens, especially when catheter use was combined with challenges in finding enough personal protective equipment and lab supplies, reduced staff, and longer lengths of stay.
“Hospitals experienced shocking numbers of very sick patients requiring intensive care, increasing the number of nosocomial infections requiring treatment, and the number of patients taking preventive antibiotics,” said LaPlante.
According to the CDC report, there was a 78% increase in carbapenem-resistant Acinetobacter from 2019 to 2020.
“Surveillance resources dedicated to antimicrobial resistance were often redirected toward COVID-19 surveillance and testing, and without proper surveillance we cannot adjust therapy guidelines accordingly to prevent the resistance from increasing,” said LaPlante.
Outpatient prescribing practices
The new CDC report noted that antibiotic use “significantly” dropped in 2020 compared to 2019 due to less use of outpatient health care and reduced spread of other respiratory illnesses that often lead to antibiotic prescriptions.
However, CDC said, outpatient antibiotic use rebounded in 2021.
“While antibiotic use was lower overall in 2021 compared with 2019, in August 2021, antibiotic use exceeded prescribing in 2019 by 3%,” CDC report authors wrote.
Telehealth prescribing practices may also warrant more scrutiny, especially when it comes to antibiotics. According to a recent study in the Journal of Telemedicine and Telecare, third-party vendor physicians appear much more likely than their health system–employed counterparts to prescribe antibiotics during acute care telehealth visits for acute respiratory infections.
“I expected to find a difference in antibiotic prescribing behavior between the affiliated and contracted physicians, but I did not expect it to be quite so pronounced,” said Kathleen Li, MD, lead author of the study from the Department of Emergency Medicine at the University of Michigan.
She said she hopes their research will encourage hospitals and health systems to consider how telehealth staffing—whether in-house or contracted out—might affect quality of care and antimicrobial stewardship.
Pharmacists must be involved
In the United States, more than 2.8 million antimicrobial-resistant infections are reported to occur each year, resulting in more than 35,000 deaths. But between 2012 and 2017, prevention efforts, like more appropriate antimicrobial use, contributed to a decrease of deaths from antimicrobial resistance by 18% overall and nearly 30% in hospitals.
“We have made progress on antimicrobial resistance in the last 7-plus years since the 2013 CDC report came out,” said Vyas. In 2013, CDC first sounded the alarm on the threat of antimicrobial resistance.
“However, COVID-19 has really thrown a curve ball into antimicrobial stewardship efforts,” Vyas said.
But one good thing to come out of the pandemic, according to Vyas, is how it has highlighted the important role of pharmacists. “The antibiotic resistance pandemic [if you will] is another avenue for pharmacists to show their importance,” said Vyas.
Even having a pharmacist there who is up to date on the newest COVID-19 therapies can ensure the patient gets the best therapy possible, said LaPlante.
“Pharmacists also review each prescription within an institution, so they are able to assess each individual prescription for the correct dose, drug, and indication. When there is a conflict, the pharmacist can reach out to the prescriber directly to resolve it,” LaPlante said. “Through this process, pharmacists can educate prescribers and lead stewardship efforts.”
Pharmacists also keep providers up to date on current antimicrobial prescribing guidelines. LaPlante said they can encourage good stewardship and prescribing practices among the larger health care provider community as well.
“It is impossible to predict the future; however, we can learn from our past and apply what we learned from this pandemic to the next one,” said LaPlante. “One of the biggest things that we learned from COVID-19 is that we need to be more prepared, and preparing for the next global pandemic, antimicrobial resistance–related or not, starts with prevention today.” ■
COVID-19 impacts on
Antimicrobial-resistant bacteria and fungi threat estimates
The following table summarizes the latest national death and infection estimates for several antimicrobial-resistant bacteria and fungi. The pathogens are listed in 2 categories—urgent and serious—based on level of concern to human health identified in 2019.
|
| |
Resistant pathogen
|
2017 threat estimate
|
2018 threat
estimate
|
2019 threat
estimate
|
2017–2019 change
|
2020 threat
estimate and
2019–2020 change
|
| URGENT |
Carbapenem-resistant
Acinetobacter
|
8,500 cases
700 deaths
|
6,300 cases
500 deaths
|
6,000 cases
500 deaths
|
Stable*
|
7,500 cases
700 deaths
Overall: 35% increase* Hospital-onset:
78% increase*
|
|
Antifungal-resistant
Candida auris
|
171 clinical cases†
|
329 clinical cases
|
466 clinical cases
|
Increase
|
754 cases
Overall: 60% increase
|
|
Carbapenem-resistant
Enterobacterales
|
13,100 cases
1,100 deaths
|
10,300 cases
900 deaths
|
11,900 cases
1,000 deaths
|
Decrease*
|
12,700 cases
1,100 deaths
Overall: Stable*
Hospital-onset:
35% increase*
|
| SERIOUS |
Drug-resistant
Campylobacter
|
448,400 infections
70 deaths
|
630,810 infections
|
725,210 infections
|
Increase
|
Data delayed due to COVID-19 pandemic‡ 26% of infections were resistant,
a 10% decrease
|
|
Antifungal-resistant
Candida
|
34,800 cases
1,700 deaths
|
27,000 cases
1,300 deaths
|
26,600 cases
1,300 deaths
|
Decrease
|
28,100 cases; 1,400 deaths
Overall: 12% increase* Hospital-onset:
26% increase*
|
|
ESBL-producing
Enterobacterales
|
197,400 cases
9,100 deaths
|
174,100 cases
8,100 deaths
|
194,400 cases
9,000 deaths
|
Increase*
|
197,500 cases; 9,300 deaths
Overall: 10% increase* Hospital-onset:
32% increase*
|
|
Vancomycin-resistant
Enterococcus
|
54,500 cases 5,400 deaths
|
46,800 cases 4,700 deaths
|
47,000 cases
4,700 deaths
|
Stable*
|
50,300 cases; 5,000 deaths
Overall: 16% increase* Hospital-onset: 14% increase
|
|
Multidrug-resistant
Pseudomonas aeruginosa
|
32,600 cases
2,700 deaths
|
29,500 cases 2,500 deaths
|
28,200 cases 2,400 deaths
|
Decrease
|
28,800 cases
2,500 deaths
Overall: Stable*
Hospital-onset:
32% increase*
|
|
Drug-resistant nontyphoidal
Salmonella
|
212,500 infections
70 deaths
|
228,290 infections
|
254,810 infections
|
Increase
|
Data delayed due to COVID-19 pandemic‡ 14% of infections were resistant, a 3% decrease
|
|
Drug-resistant
Salmonella serotype Typhi
|
4,100 infections
< 5 deaths
|
4,640 infections
|
6,130 infections
|
Increase
|
Data delayed due to COVID-19 pandemic‡ 85% of infections were resistant, a 10% increase
|
|
Drug-resistant
Shigella
|
77,000 infections
< 5 deaths
|
215,850 infections
|
242,020 infections
|
Increase
|
Data delayed due to COVID-19 pandemic‡ 46% of infections were resistant, a 2% increase
|
|
Methicillin-resistant
Staphylococcus aureus
|
323,700 cases
10,600 deaths
|
298,700 cases 10,000 deaths
|
306,600 cases 10,200 deaths
|
Stable*
|
279,300 cases
9,800 deaths
Overall: Stable*
Hospital-onset:
13% increase*
|
|
Drug-resistant
Streptococcus pneumoniae
|
12,100 invasive infections
1,500 deaths†
|
See original report
|
12,000 invasive infections 1,200 deaths
|
Stable
|
Data delayed due to COVID-19 pandemic
|
|
Drug-resistant
Tuberculosis (TB)
|
888 cases
73 deaths†
|
962 cases 102 deaths
|
919 cases
|
Stable
|
661 cases
General decrease‡
|
|
†CDC’s database allows for continuous updates for TB, C. auris, and Streptococcus. Variations in historical TB data are attributable to updated information submitted in the interim by reporting areas; this report includes data reported through June 14, 2021. For Streptococcus, table reflects infection increase for 2017 data as of October 2021. For C. auris, this report reflects clinical case increase for 2018 data.
*Changes are in rates, not comparisons of counts. Data for health care pathogens show a significant increase in hospital-onset rates of resistant infections in 2020, likely due to smaller number of overall hospitalizations during the pandemic.
‡For TB, 2019 and 2020 death reports are not available due to a 2-year lag. For enteric pathogens, 2018–2020 death estimates and 2020 estimates of total number of resistant infections are not available at this time.
COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022.
|