Two months ago, the UK entered lockdown to prevent the spread of the novel coronavirus disease, COVID-19. Across the world governments, the media and the public haven’t faced a healthcare crisis of this scale in living memory. Except, perhaps, for one.
Antimicrobial resistance (AMR) has been described as an epidemic by the World Health Organisation (WHO)1. According to the WHO definition, AMR is, “when bacteria, parasites, viruses and fungi become resistant to antimicrobial drugs that are used for treating the infections they cause”. Every year, 700,000 people die due to AMR2. If the very worst happened and the COVID-19 death toll sadly remained constant until the end of 2020, AMR would still cause over roughly 130,000 more deaths this year alone. Even more worrying, is that AMR is on the rise. It has been estimated that by the year 2050, someone will die every three seconds from an AMR infection and that this will cost over $100 trillion in global, gross domestic product (GDP)3.
Significant pandemics have long been on the UK government’s National Risk Register of Civil Emergencies. In recent years, AMR was also included as a possible long-term trend that could worsen current risks like pandemic flu. In a recently published paper, accessible here, I discussed the opposite - how COVID-19 could also have impacts on AMR. These relate to three main areas – clinical settings, the environment and in relation to public awareness.
Antibiotic use in hospital has likely massively increased due to COVID-19. There are limited data at the time of writing, but many COVID-19 patients will be given antibiotics to either treat or prevent secondary bacterial infections. There are even fewer data on antifungal infections. On the other hand, antibiotic use may have decreased generally in hospitals in non-COVID-19 patients due to reduced spread of AMR bacteria. Enhanced hygiene practices within hospitals, aimed at reducing the spread of COVID-19, will also be effective at reducing the spread of AMR; for example, isolation of patients and increased use of disinfectants to sterilise surfaces. In the community, antibiotic use may well have decreased due to scaling down and prioritisation of healthcare. Patient perception of risk of contracting COVID-19 resulting in less visits to the doctors may have reduced prescriptions in the community. We need data to find out.
All of these possible scenarios could have different impacts on AMR in the environment. Antibiotics and antimicrobials move through our wastewater treatment system and into receiving aquatic environments. Several studies have now shown that even very low concentrations of antibiotics in the environment could enrich for AMR bacteria. Some of our work has even shown that these very low concentrations can select for AMR, just as much as very high concentrations4. Alongside antibiotics, use of disinfectants will have increased not just in hospitals, but also in the community through improved and more frequent hygiene practices. These products contain antimicrobials that may also select for AMR at sub-inhibitory concentrations. On the other hand, if use has increased to the point where environmental concentrations become inhibitory, this could reduce AMR in the environment but could also adversely affect environmental bacteria that aren’t resistant, but still play key ecosystem roles.
Lockdown and especially reduced international travel will also reduce the spread of AMR. There are many cases of AMR genes being identified for the first time in one country or in the environment, then going on to pose significant problems in clinical settings, in different countries. Another potential positive outcome could be increased public interest in and awareness of transmissible diseases, such as viral pandemics or AMR. The COVID-19 pandemic could even be used as an example when communicating how AMR can become rapidly widespread, how difficult it can be to control once emerged and that a treatment or ‘cure’ isn’t always available.
The GW4 Alliance are well placed via their collective expertise in AMR, the GW4 Water Security Alliance and this year’s GW4 Crucible programme, to collaborate within and beyond GW4 on many of these potential research areas. I was recently selected to attend GW4 Crucible, which is a series of two-day workshops designed to bring together future research leaders across GW4, to forge new collaborations and develop novel, interdisciplinary ideas to combat significant global issues. The focus this year was AMR.
Lockdown began before our final workshop, but the team did a great job of moving most of the content online so it could still go ahead. We had an opportunity to discuss COVID-19 and my fellow Cruciblees raised another key point: COVID-19 highlights how development of new antibiotic drugs is key not just for combatting AMR, but also critical for our ability to respond to pandemics where secondary bacterial or fungal infections can be the actual cause of death. The Crucible programme gave me time to start thinking beyond my specific research area to consider AMR more holistically.
Compared to COVID-19, I described AMR as a more insidious healthcare issue, in that it may not have as many immediate impacts on everyday life as COVID-19 does right now, but it is a more sinister, silent killer that may have more serious impacts in the not too distant future. Hopefully, when the current crisis is more under control, we can consider what we can learn from it and use this knowledge to face future pandemics – whether they be due to a novel virus, or due to AMR.
- (Murray et al. 2018) Murray AK, Zhang L, Yin X, Zhang T, Buckling A, Snape J, et al. 2018. Novel insights into selection for antibiotic resistance in complex microbial communities. mBio 9.
Original paper: https://mbio.asm.org/content/9/4/e00969-18
Press release: http://www.exeter.ac.uk/amr/news/articles/environmentkeybattlegroun.html