Dr Phil Mitchelmore, Clinical Lecturer at the University of Exeter, Honorary Consultant at Royal Devon & Exeter Hospital and GW4 Crucible 2020 Alumni reflects on AMR against the backdrop of the COVID crisis, and how GW4 and its Crucible Alumni are set to tackle this global challenge. For the last six months, the coronavirus (COVID-19) pandemic has eclipsed all other concerns, including antimicrobial resistance (AMR). However, while our hopes and expectations are that COVID-19 will be defeated in 2021, it is highly likely that AMR will continue to be the most significant threat to global health and global economy for the coming years.
Even with the final quarter yet to start, it is safe to say that 2020 has not been the year that we had all planned or expected. As a respiratory physician with a clinical and research interest in pulmonary infection, I would have predicted a more insidious feeling of unease around the global state of infectious diseases. AMR has been the monster coming over the hill. Whilst in the UK we have been relatively lucky compared to many other nations, cases of XDR Tuberculosis, devastating sepsis, and WHO reports1 have been a stark reminder of the threat of AMR. I vividly remember hearing the news report of Colistin resistance in China on the laboratory radio as I worked on isolates of Pseudomonas aeruginosa. However, instead of AMR, centre stage in 2020 has been taken by the COVID-19 pandemic.
COVID-19 has affected everyone in different ways, sadly with devastating consequences for many. The “COVID” wards looking after people during the 1st wave were environments of truly mixed emotions. Fear and distress were prominent for patients, but also staff. However, in that adversity compassion, gratitude, learning, and teamwork shone through. An example of some good to come from this environment has been the Recovery Trial2. Via the scientists, research teams, clinicians and the patients, this multi-arm adaptive clinical trial has been a tremendous collaboration. Having opened in March, more than 12,000 patients have been recruited in 176 NHS hospitals and a treatment which can reduce mortality has been identified3. This way of working must be continued, as well as the support and interactions between Universities and the NHS. Whilst the Recovery Trial is ongoing, the next key collaborations will include vaccine trials. With a 2nd wave possibly commencing, these studies are vital.
At the time of writing, estimated global deaths from COVID-19 are approaching a million. This is more then the estimates of 700,000 yearly deaths due to AMR. With regards to COVID-19, the hope and expectation must be that these numbers will not be repeated in 2021. Sadly, the same optimism can not be had for AMR. Indeed, some predictions warn of far greater annual deaths from AMR4 than the tragic COVID-related deaths of 2020.
It is difficult to know the impact of COVID-19 on AMR. From a research perspective, the abrupt shift in focus and restrictions have halted or slowed much AMR-related work. In the clinical setting, different regions will have seen different changes in antibiotic practice. For example, a hospital in a lower prevalence area saw less antibiotics prescribed during the peak of the 1st wave than at the equivalent time in the preceding year. However, less patients were admitted and the antibiotic burden per patient was higher. The prescription of anti-bacterial drugs for viral infections of the respiratory tract, whilst counterintuitive, has long been a common occurrence. Human nature, diagnostic uncertainty and the concern of secondary bacterial infection have all contributed to this practice. This has continued to be the case during the COVID-19 pandemic. A recent study has suggested that high numbers of patients admitted with COVID-19 were given antibiotics5. The pandemic has highlighted the importance of rapid point-of-care testing to determine the aetiology of respiratory tract infections, and the ongoing development of molecular testing will hopefully lead to the more appropriate use of antibiotics for respiratory infections.
With AMR set to be the infectious diseases crisis that outlives the COVID pandemic, the GW4 Alliance is well set to be at the forefront of this field. AMR is a priority programme for GW4, and the Alliance has further illustrated its commitment to AMR via this years themed Crucible programme. I was lucky enough to be selected to be part the 2020 cohort which involved three “labs” (two-day workshops) exploring interdisciplinary and collaborative working. It was a wonderful opportunity to spend time in the company of fascinating Early Career Researchers from a wide range of disciplines in an environment skilfully optimised to allow collaboration to thrive. Via this programme I am now leading a seed-funded project with colleagues across GW4 who I met at Crucible. In keeping with the times, the final lab was “virtual”. This is a platform which has rapidly become common place. It presents different challenges and requires different skills, which the facilitator mastered and nurtured. 2021 sees the GW4 Crucible focus on Climate Change, and I would strongly encourage interested ECRs to apply.
We must hope that the COVID-19 pandemic has evolved our skills and working to address the challenge of AMR. The importance of infectious diseases, diagnostics, public health, innovative working, widespread collaboration and accelerated clinical trials and vaccine development, have all been features of this pandemic which we must take forward. GW4 is ready for this challenge and has a cadre of motivated ECRs to take this on.
- RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19 - Preliminary Report. N Engl J Med. 2020 Jul 17:NEJMoa2021436. doi: 10.1056/NEJMoa2021436. Epub ahead of print. PMID: 32678530; PMCID: PMC7383595.
- Beović B, Doušak M, Ferreira-Coimbra J, Nadrah K, Rubulotta F, Belliato M, Berger-Estilita J, Ayoade F, Rello J, Erdem H. Antibiotic use in patients with COVID-19: a 'snapshot' Infectious Diseases International Research Initiative (ID-IRI) survey. J Antimicrob Chemother. 2020 Aug 7:dkaa326. doi: 10.1093/jac/dkaa326. Epub ahead of print. PMID: 32766706; PMCID: PMC7454563.