Antimicrobial Use and Hygiene Practices During the COVID-19 Pandemic Could Be Driving AMR

From scratching the surface, it would appear as if COVID-19 and antimicrobial resistance (AMR) are linked in one fundamental way, the fact that both are severe global health crises with massive socioeconomic implications. This is testament to worldwide imposition of lockdowns and restrictions as governments try to curb COVID-19 infection rates and the ever increasing COVID-19 related mortalities, with economic recession and erosion of social discourse in many nations being the side effects. In the same vein, AMR is among the thirteen urgent global health threats pointed-out by WHO (1). Estimates suggest that if AMR is not addressed now, by 2050 it would cause ten million deaths yearly and the world’s GDP would plummet by 2 to 3.5% amounting to a loss of 100 trillion USD (2). To make the matters worse, more evidence is being gathered which suggests that the rabbit hole runs deeper than meets the eye with COVID-19 and AMR being interconnected in various, complex ways.

    1. Antimicrobial Use Amidst the Pandemic

WHO reports that inappropriate use of antibiotics in hospitals has spiked since the inception of the COVID-19 pandemic, a phenomenon which could be driving AMR (3). This is confirmed by a study conducted in China which reports that even though the bacterial infection rate was a mere 1% among hospitalized COVID-19 patients, a staggering 71% of patients still received antibiotics (4). Despite lack of evidence of a synergistic effect between SARS-CoV-2 and certain bacterial infections, combination therapy between azithromycin (antibiotic) and hydroxychloroquine (antimalarial) is being used especially in low resource settings, as treatment to combat COVID-19 (4,5). The rationale behind this therapy usage is the reported promising in-vitro efficacy of the drugs displayed against SARS-CoV-2. Follow-up clinical studies on the drugs have yielded varying results, some reporting up to 71% mortality reduction while others have found no benefits at all on COVID-19 patients. WHO, through the Solidarity Trial, is conducting clinical trials to establish effectiveness of antivirals remdesivir, lopinavir, ritonavir as well as hydroxychloroquine in COVID-19 patients (4,5). Ivermectin, an anthelmintic medicine, is also gaining prominence in COVID-19 management, signaling how the pandemic could contribute to an increased antimicrobial use and ultimately AMR.

In terms of antimicrobial use in the community, initial predictions in the early stages of the pandemic anticipated a sharp drop in antibiotic consumption due to fewer patient consultations (6). On the contrary, wide adoption of telemedicine such as video call consultations during the pandemic has brought unexpected consequences. Data collected from the UK depicts a high rate of antibiotic prescribing during the pandemic, a 6.71% increase from the expected prescribing rate (7). This phenomenon has been attributed to clinicians prescribing inappropriately during telephone consultations, coupled by uncertainty in diagnosis as doctors are unable to conduct physical assessments of the patients. Consequently, clinicians have resorted to precautionary prescribing during remote consultations thus potentially adding fuel to the AMR problem (7). Self-medication could be another source of concern during the lockdowns (6), whereas others, especially in low resource settings, have been using traditional herbal remedies to manage symptoms of COVID-19.

Figure 1: Video call consultations have facilitated healthcare appointments during the pandemic potentially driving a spur in antibiotic prescriptions (6, 10)

    2. Hygiene Practices and Changes in Public Health During the Pandemic
While rampant hand hygiene practices, physical distancing, face mask usage and disinfection of the environment have been crucial to preventing COVID-19 and AMR, there are reasonable grounds to believe that some of the measures may have a paradoxical effect in terms of reducing AMR (5,6). Disinfectants, sanitizers and cleaners contain biocides which are ingredients that possess the antimicrobial activity in the products, hence excessive use of these products has been implicated among the causes of AMR (5). During the COVID-19 pandemic, environmental concerns have been raised on the possibility of high concentration biocide-based products seeping into surface and underground water reservoirs as well as waste treatment systems. Microbial species are very sensitive to biocide concentrations as sufficiently high levels can successfully kill most microbes while preventing AMR. Alternatively, low concentrations (below the minimum inhibitory concentration) may facilitate selection of resistant bacteria and AMR through horizontal gene transfer and efflux-mediated mechanisms (5). This is important in light of cheap quality unregulated biocide-based products flooding the market especially in low and middle income countries. WHO has since weighed in on the issue and discouraged inappropriate use of these products during the pandemic (8).

Figure 2: Pharmaceutical waste in waterbodies providing the perfect breeding ground for resistance in microbes (5,11)

In regards to public health policies, COVID-19 is expected to derail a host of health initiatives and set goals. National AMR action plans and stewardship programs will be affected as well as infant immunization and tuberculosis management initiatives (6,9). This is a consequence of policy makers prioritizing viral infections and emphasizing preparedness for emerging viral infections. Low to middle income countries could be the hardest hit by this policy shift and a rise of vaccine preventable diseases is a possible outcome as the health systems are overwhelmed and resource depleted (6). Solace can be taken in the fact that various stakeholders such as university students are trying to raise awareness on AMR and pressure policy makers to put AMR on the priority list by holding various webinars within the lockdowns as evidenced by the first ever AMR youth summit held virtually in November 2020 addressing all issues pertaining AMR.

In conclusion, the COVID-19 pandemic has a greater potential of being a perfect breeding environment for AMR than not, hence making sure antimicrobial stewardship activities are incorporated in pandemic response could present a giant leap towards successfully eradicating both public health threats. However, this requires unity of purpose and cooperation from various key stakeholders worldwide.

Author Information:

Leeroy Kakava is a 22 year-old, pharmacy student at Harare Institute of Technology (HIT),Harare, Zimbabwe. Academically, he holds a keen interest in global public health and medical research. He is also a freelance blogger on health and social issues. Leeroy takes pleasure in hearing different perspectives and opinions from people of various backgrounds. He also holds a passion for making a difference in the world, and believes he can do so through writing and promoting social justice. Leeroy is also interested in voluntary work as he views it as a noble way to serve others and contribute to the society. He enjoys watching sport in his free time and is an avid soccer fan.

Useful Links & Reference Points: 

1. (WHO). (2020b). Urgent health challenges for the next decade. News Room. https://www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade

2. Neill, J. O. ’. (2014). Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations The Review on Antimicrobial Resistance Chaired. December.


3. (WHO). (2020a). Preventing the COVID-19 pandemic from causing an antibiotic resistance catastrophe. https://www.euro.who.int/en/health-topics/disease-prevention/antimicrobial-resistance/news/news/2020/11/preventing-the-covid-19-pandemic-from-causing-an-antibiotic-resistance-catastrophe


4. Lucien, M. A. B., Canarie, M. F., Kilgore, P. E., Jean-Denis, G., Fénélon, N., Pierre, M., Cerpa, M., Joseph, G. A., Maki, G., Zervos, M. J., Dely, P., Boncy, J., Sati, H., Rio, A. del, & Ramon-Pardo, P. (2021). Antibiotics and antimicrobial resistance in the COVID-19 era: Perspective from resource-limited settings. International Journal of Infectious Diseases, 104(52), 250–254. https://doi.org/10.1016/j.ijid.2020.12.087


5. Rezasoltani, S., Yadegar, A., Hatami, B., Asadzadeh Aghdaei, H., & Zali, M. R. (2020). Antimicrobial Resistance as a Hidden Menace Lurking Behind the COVID-19 Outbreak: The Global Impacts of Too Much Hygiene on AMR. Frontiers in Microbiology, 11(December), 1–7. https://doi.org/10.3389/fmicb.2020.590683


6. Monnet, D. L., & Harbarth, S. (2020). Will coronavirus disease (COVID-19) have an impact on antimicrobial resistance? Eurosurveillance, 25(45), 1–6. https://doi.org/10.2807/1560-7917.ES.2020.25.45.2001886


7. Armitage, R., & Nellums, L. B. (2020). Antibiotic prescribing in general practice during COVID-19. The Lancet Infectious Diseases, 3099(20), 30917. https://doi.org/10.1016/S1473-3099(20)30917-8


8. Getahun, H., Smith, I., Trivedi, K., Paulin, S., & Balkhy, H. H. (2020). Tackling antimicrobial resistance in the COVID-19 pandemic. In Bulletin of the World Health Organization (Vol. 98, Issue 7). World Health Organization. https://doi.org/10.2471/BLT.20.268573


9. Rawson, T. M., Ming, D., Ahmad, R., Moore, L. S. P., & Holmes, A. H. (2020). Antimicrobial use, drug-resistant infections and COVID-19. Nature Reviews Microbiology, 18(8), 409–410. https://doi.org/10.1038/s41579-020-0395-y


10. Medico Digital: https://www.medicodigital.co.uk/digital-marketing-for-clinics-and-doctors/


11. ReAct: reactgroup.org/news-and-views/news-and-opinions/year-2020/antibiotic-pollution-india-scores-a-global-first-with-effluent-limits/