Health risks of antibiotic misuse and abuse amid Covid-19

The use and abuse of antimicrobials has been identified as the hidden threat lurking behind the pandemic.

In Summary

•Despite these cautions, Kenyans have continued to abuse over-the-counter antibiotics to treat what they suspect are COVID-19 symptoms. 

• The self-medication and abuse of antibiotics is not a new phenomenon. 

The COVID-19 pandemic has by February 14 claimed the lives of over 5,632 Kenyans. At the start of the outbreak in March 2020, the ministry of health issued treatment guidelines and recommended the use of various antibiotics in the management of COVID-19. https://bit.ly/3v1Dm0i

Antibiotics are a critical tool for fighting infection./courtesy
Antibiotics are a critical tool for fighting infection./courtesy

The COVID-19 pandemic has by February 14 claimed the lives of over 5,632 Kenyans.  At the start of the outbreak in March 2020, the ministry of health issued treatment guidelines and recommended the use of various antibiotics in the management of COVID-19.

The use and abuse of antimicrobials has been identified as the hidden threat lurking behind the pandemic and has increasingly become a cause of concern.

AWJP Fellow Nelly Madegwa looks at the causes of the crisis which has major public health consequences including the slow development of new antibiotics.

A rapid review of the COVID-19 treatment guidelines in Kenya and nine other African countries recommended governments to be cautious in recommending the use of  various antibiotics, such as azithromycin, doxycycline, clarithromycin, ceftriaxone, erythromycin, amoxicillin, amoxicillin clavulanic acid, ampicillin, gentamicin, benzylpenicillin, piperacillin/tazobactam, ciprofloxacin, ceftazidime, cefepime, vancomycin, meropenem, and cefuroxime among others, in the management of COVID-19.This is worrisome in that COVID-19 is a viral disease and only a few COVID-19 patients would have bacterial co-infection. [There is ] need to emphasize prudent and judicious use of antibiotics in the management of COVID-19 in Africa,” the report states.

The WHO also urged caution in the use of antibiotics (a type of antimicrobial) to treat COVID-19 . “The bottom line is that antibiotics treat bacteria and not viruses, and SARS-CoV-2, or COVID-19, is a disease caused by a virus. So there is really no recommendation for treating antibiotics for COVID-19 as a pathogen or as a disease.”

Despite these cautions, Kenyans have continued to abuse over-the-counter antibiotics to treat what they suspect are COVID-19 symptoms.  The self-medication and abuse of antibiotics is not a new phenomenon. 

Even before the COVID-19 pandemic, antimicrobial abuse has been a major public health challenge. According to the WHO antimicrobial resistance of which antibiotic resistance a subset of  is a "hidden" pandemic that threatens healthcare delivery worldwide and kills an estimated 750,000 people each year with recent estimates indicating that the largest toll is most likely occurring among children in some of the poorest countries in the world. 

A 2021 global survey found that 79% of physicians treating newborns reported an increasing trend of multi-drug-resistant infections over the last five years, while 54% cited antimicrobial resistance as the leading cause of failure to treat neonatal sepsis, a blood infection affecting newborns.

What is antimicrobial resistance?

Antimicrobials – including antibiotics, antivirals, antifungals and antiparasitics – are medicines used to prevent and treat infections in humans, animals and plants.

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. 

As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat. If we end up with no antibiotics to treat infections, we will basically be losing significant advances in healthcare as we have it today especially in the treatment of cancer, surgery, transplants, complicated deliveries and treatment of preterm babies whose successful outcomes rely largely on effective antibiotic treatments.  

Some of the factors that have increased the threat of antibiotic resistance include overuse and misuse of medicines in humans, livestock and agriculture as well as poor access to clean water, sanitation and hygiene.

Why is AMR increasing?

Poor medical prescribing practices and patient adherence to treatment also contribute. For example, antibiotics kill bacteria, but they cannot kill viral infections like colds and flu. They are also often incorrectly prescribed for those illnesses, or taken without proper medical oversight as people can easily access them without prescription. Antibiotics are also commonly overused in farm animals (whether in animal feeds, to treat infections, prevent diseases or promote growth). 

Lack of access to clean water, sanitation and hygiene (WASH) for both humans and animals – Lack of clean water and sanitation in health care facilities, farms and community settings and inadequate infection prevention and control promotes the emergence and spread of drug-resistant infections.COVID-19 – The misuse of antibiotics during COVID-19 pandemic has contributed to accelerated emergence and spread of antimicrobial resistance. COVID-19 is caused by a virus, not by a bacteria and therefore antibiotics should not be used to prevent or treat viral infections, unless bacterial infections are also present. 

Why is Antimicrobial resistance a health concern?Bacteria, not humans or animals, become antibiotic-resistant. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria. Antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality. 

If nothing changes, by 2050 AMR will be the leading cause of death, with an estimated 10 million deaths, surpassing the estimated 8.2 million deaths due to cancer. This would mean one person every three seconds. In Africa, AMR could kill 4.1 million people across Africa by 2050 unless measures are taken to stop the abuse and misuse of antibiotics.

Developing countries across Africa could lose up to 5% of their GDP as a result of AMR. That means the financial toll of antimicrobial resistance would be deeper than the 2008 financial crisis.

As it is, countries of all income levels are reporting alarming levels of antimicrobial resistance. High rates of drug resistant bloodstream bacterial infections. Close to half a million people, mostly in low and middle income countries including Kenya, developed drug resistant TB in 2019, of which only 38% received treatment.

Resistance to antimalarials and insecticides as well as increasing resistance to HIV drugs threatens the progress made so far. Likewise,  Candida auris, a multidrug resistant fungal infection which was first reported in 2009, has now spread to all continents with high mortality rates of up to 60%. 

 In 2019, the WHO identified AMR as one of the major threats facing healthcare systems. This situation has been  further complicated  by among others, the pressures placed on health care providers to repurpose drugs to treat COVID-19,  the deteriorating economic conditions, and the shifting of resources away from antimicrobial stewardship programs resulting in the indiscriminate use of antibiotics in COVID-19 treatment.

Antimicrobial resistance can occur in bacteria, viruses, fungi, and parasites. Some examples include Tuberculosis, an airborne lung disease which was a major killer before antibiotics became available. More recently, drug resistant forms of TB have emerged where standard antibiotic treatments do not work.

Kenya is among the top 30 high burden countries for TB, MDR TB and TB-HIV with the WHO estimating that 1.3% of new TB cases and 4.4% of previously treated TB cases have multiple drug resistance (MDR) TB or have a TB strain that is resistant to the first-line antibiotic Rifampicin. A person who has TB that is not drug-resistant will require daily treatment with several drugs for 6 to 9 months.Drug-resistant TB is more complex to treat and the person is required to take the drugs for a longer period, has to be closely monitored and in many instances, failure to manage the disease can result in death.

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterial infection that people usually get when they are staying in a hospital and can be fatal. In the past, it was a well controlled infection but it has now become difficult to treat because of resistance to some antibiotics. 

Gonorrhea is a sexually transmitted bacterial infection that can increase the rates of HIV transmission and acquisition among both men and women. Antibiotics usually used to treat gonorrhea are decreasing in effectiveness due to multidrug resistance. For instance, Kenya has switched from using ciprofloxacin, a drug that was commonly used to treat gonorrhea and which proved ineffective as the bacteria has become resistant to this antibiotic. Currently gonorrhea is treated with cephalosporins (a group of antibiotics used for various bacterial infections such as respiratory infections, skin infections, bone infections, and urinary tract infections. They cannot be used to treat viral infections).

 The gains made in the fight against HIV would be reversed if antimicrobial resistance is not brought under control. Drug resistance HIV develops when people do not adhere to a prescribed treatment plan, often because they do not have consistent access to quality HIV treatment and care. 

People with HIV drug resistance  antiretroviral therapy are less ineffective and may also transmit drug-resistant viruses to others. The viral load  in their blood will increase, unless they change to a different treatment regimen, which could be more expensive – and, in many countries, still harder to obtain.

Effective antiviral treatment for HIV can now prevent this condition from becoming more severe; it can also  reduce viral load HIV to such small quantities that it can no longer be detected by standard blood tests. People living with HIV who have an undetectable viral load can not transmit the virus.

 Drug resistant Malaria parasites have evolved in many parts of the world including Kenya. Malaria is responsible for 445,000 deaths globally, causes the deaths of 3,000 children in Africa every day and kills an estimated 10,700 Kenyans every year. An estimated 3.5 million new infections are reported annually.  The emergence of drug resistance malaria is extremely dire for Africa where 90% of  malaria cases and deaths worldwide occur. 

Artemisinin and its derivatives are a group of drugs commonly used to treat malaria. Artremisinin and its derivatives are usually administered alongside other ‘partner’ drugs in what are called artemisinin-combination therapies (ACTs) , because multiple drugs are more difficult for parasites to develop resistance against.

The emergence of a strain of malaria that is resistant to these drugs might culminate in a ‘super resistant’ parasite that becomes dominant could lead to a huge death toll and roll back the benefits many countries are making in the management and control of malaria.

Why antimicrobial resistance a concern during COVID-19 pandemic

During the COVID -19 pandemic , the most abused and misused antimicrobial medicines were  antibiotics thus best exemplifying the issue of antimicrobial resistance. The more the bacteria are exposed to antibiotics through  treatments that are unnecessary, they will develop resistance. And with COVID, there's a very large expansion in the number of patients with respiratory disease who feel the urge to take an antibiotic, while in reality COVID is not a bacteria, it's a virus.

A 2021 study found that among patients who went to hospital with coronavirus, 72% were given an antimicrobial they did not need. Only 8% had infections that were treatable with this life-saving medicine.

“Although antibiotics have always been prescribed to protect against bacterial superinfections in virally infected individuals, like the COVID-19 patients, we should note that these antibiotics are not meant to clear/treat COVID-19 (SARS-CoV-2) virus. Therefore misuse of these antibiotics, especially when the symptoms are very mild, have a danger of aggravating the development of antibiotic resistance. Such resistance is already putting pressure on the available antibiotics and it is estimated that in the next 25 to 30 years, antibiotic resistance will be the leading cause of deaths globally. Therefore my advice is that any suspected COVID-19 infected persons should seek guidance from a clinician on the best management strategy“  Dr Eddy Odari says.

What you can do to prevent AMR

Only take antimicrobial medicines if they are prescribed by qualified health personnel. Taking medicines without a prescription is dangerous!  Also is taking antimicrobial medicines or any other  when you don’t need them or failing  to complete the full dosage as prescribed when you are sick.  When  you take them when you don't need them, for example for an illness they're not meant to treat, they can stop working against a particular infection when we need them most.

Ensure the medicine you take is not a counterfeit or substandard. Remember, 1 in 10 medicines circulating around the world is substandard or not a real drug at all. Buy your antimicrobials from a licensed medical pharmacy and not from the market. 

Complete your prescribed treatment course even if you feel better. A good tip is to use a calendar or set a reminder to make sure you don't forget to follow your treatment.

 Don't keep leftover medicines "just in case" you need it again.

Don't give your leftover prescriptions to someone else even if they have similar infections. 

Don't take pills that were prescribed or recommended by someone other than a medical practitioner.

Stay  healthy— washing your hands, practising good hygiene, wearing masks, sneezing into your elbow, using protection during sexual intercourse and most important, getting  vaccinated against all vaccine-preventable diseases including COVID-19.

Be medicine smart—Before you buy an over-the- counter antibiotic, consider whether the medicine will make you better or whether it will stop working if you take it without prescription.If you have coronavirus symptoms, you must not take antibiotics because there is currently no effective treatment and you could put your life and the lives of your loved ones at risk.

“This article was produced by the Africa Women’s Journalism Project (AWJP) in partnership with Article 19, Meedan and the International Center for Journalists (ICFJ).”

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