By, Lecturer in Biomedical Sciences, Brunel University London, Originally published at The Conversation
The heroic efforts of researchers and healthcare professionals globally will eventually help us gain control of the coronavirus pandemic and there will be a decrease in the rate of new infections. The focus is still rightly on the damage this pandemic is causing, the devastating loss of life and the impact on businesses and livelihoods. But we also need to look at other prevalent crises that are affecting our healthcare systems and anticipate the impact that the COVID-19 pandemic will have on them.
One of the greatest threats to healthcare systems, around the world, is antibiotic resistance. The lack of effective antibiotics and the emergence of bacteria that are resistant to the drugs we have has resulted in the antibiotic resistance crisis.
More than 90% of people will be prescribed an antibiotic at some point in their lives. But prescribing antibiotics is a finite process. We do not have an endless supply of antibiotics to replace those that are no longer effective, and hardly any new antibiotics are being developed. In the meantime, bacteria have become resistant to more of the antibiotics in routine use and even to antibiotics of last resort (drugs with severe side-effects that are only used when all other antibiotics have failed).
We have now reached a point where infections are being seen in hospitals around the world that are resistant to all known antibiotics.
Secondary Infections
The COVID-19 pandemic has led to huge numbers of people with compromised immune systems being admitted to hospitals, which are a known breeding groundfor drug-resistant bacteria. Because of this influx, these hospital-associated bacteria will now have a much wider potential target group.
Emerging evidence suggests that high numbers of COVID-19 patients are being diagnosed with secondary infections while in hospital. The source and specific nature of these infections are yet to be fully explored, but there is some evidence that multidrug-resistant bacteria are among the germs causing these secondary infections.
These secondary infections appear to be having an impact on patient survival, with data from Wuhan showing that half of all COVID-19 patients who died had a secondary infection. That is because many of these hospital-associated bacteria are specifically adapted to establish infection in people with a weakened immune system.
History suggests that the mortality rate of viral pandemics is heavily influenced by secondary bacterial infections with large numbers of people in the 1918 and the 2009 flu pandemics succumbing to secondary bacterial infections rather than the virus itself.
Many of the patients who died during the 1918 flu pandemic, died of secondary infections. Harris & Ewing/Wikimedia Commons
The other factor that will have a significant impact on the antibiotic resistance crisis is the widespread use of antibiotics in COVID-19 patients.
Emerging data suggests that more than 90% of COVID-19 patients are also receiving antibacterial treatment. This rapid increase in antibiotic use, particularly in hospitals, will apply a strong selective pressure on bacteria to evolve resistance. This will probably contribute to an increase in the incidence of drug-resistant infections in the months and years after the pandemic is over.
A report published in 2016 suggested that by 2050, 10 million people a year could die from antibiotic-resistant infections. Given this prediction did not account for the devastating impact of COVID-19, this timeline will almost certainly have to be revised.
However, concerted efforts are being made to better understand antibiotic use in COVID-19 patients. The US Department of Defense has just launched a study to track antibiotic usage and the rate of secondary infections among COVID-19 patients. The results of studies such as this will help guide doctors on when and how to prescribe antibiotics for COVID-19 patients.
New Drugs
According to the World Health Organization, 252 antibiotic drugs are in preclinicaldevelopment – that is, they are currently being tested on animals. Unfortunately, only between two and five of these drugs will make it to market over the next decade.
One of the biggest hurdles in bringing these drugs to market is the prohibitive costs, which can be up to US$1 billion per drug (£816 million). This makes it difficult to recover investment and places a huge financial burden on the companies developing these drugs, many of which collapse under the strain. By addressing this financial burden and making the development of new antibiotics a global research priority, similar to what is being seen in the efforts to develop a COVID-19 vaccine, we can ensure more of the antibiotics being developed make it to market.
Hopefully the response to the COVID-19 pandemic can be used as a blueprint in global cooperation to tackle the antibiotic resistance crisis, a threat that has the potential to cripple our healthcare systems and medicine as we know it.
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One of the biggest hurdles in bringing these drugs to market is the prohibitive costs
And, something the article doesn’t make too clear, the lack of expected returns on investment. If new antibiotics are developed that can fight resistant strains, they’re likely to be severely restricted to those cases where they’re needed. Which isn’t how drug companies make money. They want as many people as possible to use their products as often as possible. Treatments for male baldness and erectile dysfunction are sure money-spinners; drugs designed almost not to be used are money down the drain from the corporate viewpoint.
There are plenty of potential new antibiotics being discovered. It’s our profit-oriented system keeping them out of doctor’s armouries.
I think you ought to separate development and manufacture of pharmaceuticals. A company develop a new drug, world health authorities pool their money and buy the right to it and put it in the public domain where generic manufacturers can take over. That way the cost of the medicine will reflect only the marginal cost of production, ensuring that as many as possible will have access to it.
Deciding a fair price for the original rights is tricky, but even if you pay significantly more than a “fair” price, it’s still better than today, at least if your goal is to help as many people as possible,
There are initiatives along those lines, but there still isn’t much money to be made from something to be kept from as many people as possible, meaning even most generics manufacturers aren’t over keen on the idea. As soon as it’s used, resistance will start developing, and the more it’s used, the faster.
Just another reason why we need the NIH to go into drug production full scale – from research to packaging for antibiotics, antivirals, and all of the most vital drugs such as insulin, heart meds et al.
“This makes it difficult to recover investment and places a huge financial burden on the companies developing these drugs”
Just what we need– more public subsidies for the pharmaceutical industry. These private companies want to profit from public health problems, not solve them. Given their track record, I favor socialized medicine.
Need to broaden the arsenal.
Widen the use of phage therapy.
https://en.wikipedia.org/wiki/Phage_therapy
Re: AEL’s comment on phage therapy, a resounding yes. Suggest subscribing to the newsletter for the latest information on this: Capsid & Tail
And this quote from the article above:
As one who contracted one of WHO’s top antibiotic resistant bacterial infections, Pseudomonas aeruginosa, from a beautiful but contaminated Florida river (agricultural runoff), I’m aware that it is a nasty infectious bacteria thought to be most often contracted in hospitals and nursing homes. When I saw photos of COVID-19 ICU’s designed for 7 patients crowded with 20, I thought that hospital infections must be occurring. We need to realize, at least now, that there is great peril in treating secondary infections with antibiotics unless and until the infection is cultured and when identified, antibiotic(s) are also tested against the infection for efficacy. That testing takes time.
And what will be the toll on the patient already with a virulent coronavirus if their immune system is further compromised with antibiotics? We have to realize that they now have an extremely dangerous side.
And let us not forget antifungals: there is growing resistance to those as well and there are far fewer antifungals than antibiotics to begin with (fungi are much closer to us than bacteria, making drugs that kill them but not us harder to develop; in fact most antifungals have high toxicity).
Sorry, but hanging up every single problem on the current pandemic is just opportunistic.
Every flu season, which happens every winter like clockwork, will do the same thing: people get antibiotics due to secondary bacterial infection or cause their doctor needs to pander to their expections: flu is a virus and doesn’t respond to antibiotics, only possibe secondary bacterial infections, when the snot turns yellow or green, do. Patients however need some good medicine to be satisfied, ideally antibiotics which is what they expect and sometimes demand.
Yes, CoVid-19 will make us reach the bad number of 10 million maybe a year or two earlier than 2050, but then it might not, since, (sorry for the callousness) “enough” people die right now of CoViD-19 so that they don’t need antibiotics in later life reducing the opportunities for bacteria to get further resistant. Or a thousand other things that can happen until 2050.
This again seems to be an article by someone who has a different field which is only tangentially related and now writes articles about the current theme du jour so he gets some attention. Just as someone else wrote in the comments a few days ago that every NGO tries to connect their field of expertise to the current pandemic to maybe get something of the money or attention.
Nosocomial infections and antibiotic resistance are big concerns to clinicians treating patients in hospitals.
What evidence do you present that hospital acquired secondary infections will not occur in COVID19 hospitalized patients?
I will concede a point in your favor though, perhaps the greatly increased usage of PPE and newly focused attention to personal and environmental cleaning will have a positive effect on hospital acquired infection rates. Keep in mind though, a non COVID19 patient who gets it in the hospital is considered a sufferer of a hospital acquired infection.
The abx resistance problem was noted and written about before COVID19, I don’t see how the author’s warning should be discarded after the evidence they presented.
Of course secondary infection will occur, and of course will be treated with antibiotics and of course will make bacteria more resistant statistically.
However: right now 3 million people are infected worldwide. My guess is, more people will get antibiotics prescribed by their doctor in a normal flu season in Europe or the US alone, even when they have the flu and not a bacterial infection than will get it with the current pandemic. And livestock will get 100x more antibiotics, at least, in the same time. With CoVid-19 only those actually needing it get it since it’s administered in hospitals.
Simply, the real problem of MDR has nothing to marginally nothing to do with the current pandemic: it’s a rounding error. For the pandemic the main issue is that there are already so many MDR resistant bacteria, not that the pandemic creates noticeably more of them.
Also, I don’t believe the figures put forth by pharma companies regarding drug development costs. Last time I looked at this in detail (in the 2000s) it turned out they include in that their opportunity cost, i.e., the difference between what the drug might earn them and what they could earn if they deployed their capital differently. This puts manufacturing in competition with more lucrative financial shenanigans, allowing pharma executive to inflate their so-called development costs at will, simply by assuming high enough profits from alternative capital uses. It’s completely unsound intellectually.
But but but we are in a phase of mankind’s history where money is freeeee so why shouldn’t there be absolute armies of scientists producing drugs out the wazoo?
They just need to adopt the Silicon Valley/WeWork mindset.
Normally if someone loans money to someone else for a year they get paid (something called “interest”) in return for not having that money for the year and for taking the risk they will never see it again. That payment is now zero.
Our Lords of Money have figured this out long ago for the benefit of bankers. Step 1. Bank loans money; Step 2. Bank earns no return for their risk; Step 3. Bank cries to Papa-All-Seeing-Eye-Ultra-Bank and gets bailed out.
It’s simple: we just need a bailout of the bailout of the bailout! Silly people, you just thought we needed the “two-bailout” version when obviously we just need the three-bailout version! Free drugs for all! Hey this capitalism stuff is easy!
(Squeaky little voice from the back of the class: “Um but sir how will money have any value if it pays no return to someone willing to hold it and lend it out?”)
To hitch a ride on the momentum of Covid-19 is a good idea. We have very good technology. And the whole industry is focused and looking like critical mass. There could be good new drugs being developed by small companies everywhere. I’m also hoping that we review where we’ve been. The doctors in Thailand have, reportedly, done a good job using drug cocktails to cure Covid. Now we’re all focused on South Africa, where there is an underlying and ongoing epidemic, or two, of tuberculosis and HIV. This is going to be interesting. Because, the Thai doctors used an HIV drug in their mix, and it has been reported that BCG is helpful. If Africa does not have Covid-19 in the expected pandemic proportions, it will have been an instructive example, imo. Let us all hope Africa has the mildest of all the epidemics.
80% of antibiotics are used on livestock(I am a former grass fed cattle farmer and did not use them).Perhaps that would be a good place to stop antibiotic resistance by not using them(of course that means the end of CAFOs Heaven forbid!).
Question, please. How are ‘agricultural antibiotics’ given? I imagined that they would be mixed into feed, basically handled by the bucketfull. I imagined that this would give bugs the best opportunities to find sub-lethal doses of the drugs just lying around, and to become super.
Am I anywhere near the facts?
Worse than that. What you said + cows fed mostly on corn are like humans living on ice cream. It turns their digestive systems into mutation production machines.
I remember industrial pig farming was a huge concern for swine flu, due to its abuse of antibiotics
The industrial pig farming link to flu is because pigs catch both human and bird specific strains of flu which allows the strains to share genetic info and create novel flu strains which is as bad for birds as it is for us. In addition the overcrowding, poor health, genetic invariability of the pigs and antibiotic abuse is horrible and causing deadly bacterial evolution (as in all large confined animal facilities).
I have often reflected that the use of antibiotics will not be able to continue very much longer, and after nearly 100 years of use perhaps we cannot expect their use to be eternal. The over-use in general practice (as patients “ask for” and “expect” them regardless of need), the excessive and dangerous use as “growth factors” in intensive animal production for food, make it very likely that each “new” one will before long be useless because of resistance built up in the populations.
I well remember MRSA in Australia, when the surgeons and physicians did not like being told to keep to the strict hygiene rules enforced by nursing staff, after it was found that they were among the spreaders of MRSA in hospitals. Now we are learning that everyone needs to be involved in strict hygiene and other forms of protection, but there are still disagreements on how important different gestures are.