key: cord-0786398-8k0clugw
authors: Daria, Sohel; Islam, Md. Rabiul
title: Indiscriminate Use of Antibiotics for COVID-19 Treatment in South Asian Countries is a Threat for Future Pandemics Due to Antibiotic Resistance
date: 2022-05-18
journal: Clin Pathol
DOI: 10.1177/2632010x221099889
sha: 58d1126835159435ca57e79f0617b600ce125069
doc_id: 786398
cord_uid: 8k0clugw

The COVID-19 pandemic has put enormous strain on the global public health and healthcare systems. Here we aimed to assess the prevalence and impact of indiscriminate use of antibiotics for COVID-19 treatment in south Asian countries. We observed the indiscriminate use of antibiotics in south Asian countries and other similar parts of the world. Along with vaccines, people in poor and developing countries have been taking antibiotics and some other medications without proper jurisdiction during the waves of the COVID-19 pandemic. We all know that COVID-19 is a viral disease, and only a few patients might have bacterial co-infections. Therefore, the role of antibiotics is ambiguous in most COVID-19 cases. Consequently, the overuse of antibiotics would cause antimicrobial resistance that has the potential to become a 2-edged sword after the COVID-19 pandemic era. Our findings emphasize the judicious use of antibiotics in COVID-19 therapy, especially in poor and developing countries across the globe.

The COVID-19 pandemic caused by novel coronavirus strain SARS-CoV-2 reveals various loopholes and fragility of the healthcare systems worldwide. 1 This ongoing pandemic badly impacted every aspect of public health and healthcare systems in any country. [2] [3] [4] [5] [6] The impact of this pandemic in south Asian countries is high where healthcare systems are more fragile. [7] [8] [9] Most COVID-19 patients develop mild/moderate symptoms (eg, fever, cough, tiredness, loss of taste and smell, difficulty breathing, or shortness of breath) that resemble a bacterial infection. Only 6% of the infected patients became critically ill and required ICU support. Moreover, only 20% of the intensive care unit (ICU) patients had a severe infection. 10 Physicians frequently prescribe different antimicrobials for COVID-19 patients due to the scarcity of an antiviral treatment approach and vaccine against COVID-19. Also, it is tough to differentiate between COVID-19 and bacterial pneumonia at the very early stage by examining the symptoms. 11, 12 Study shows that 72% of COVID-19 patients got different types of antibiotics for their COVID treatment. However, only 1% to 16% of bacterial co-infection occurred who received antibiotics. 13 Studies found that in south Asia, about 70% of hospitalized patients have been administered a minimum of one or more antibiotics, whereas 100% of ICU patients received antibiotics. 11, 12 Besides broad-spectrum antibiotics, many physicians indiscriminately prescribe antiviral, antimalarial, and antiparasitic drugs for COVID-19 patients. In Bangladeshi hospitals, the highest prescribed antibiotics were third-generation cephalosporins (60%) followed by macrolide (40%). Many patients who took antibiotics for COVID-19 treatment with earlier symptoms were found COVID-19 negative after the confirmatory test. 13 An interrupted time series analysis revealed a significant increase in non-CAF antibiotic sales during the first wave of the COVID-19 pandemic. 14 A study conducted in Pakistan found that 88.1% of patients received multiple antibiotics without any culture and sensitivity tests. Azithromycin was the most frequently prescribed antibiotic to treat COVID-19 patients. 15 A study reported that antibiotic sales significantly increased during the first wave of COVID-19 epidemic in India. 14 Frequent prescribing of antibiotics, availability of overthe-counter antibiotics through unregulated/unauthorized medicine shops (pharmacies), and uncontrolled use of antibiotics contribute to the current challenge of antimicrobial resistance (AMR). The situation has worsened due to the COVID-19 pandemic that will complicate the healthcare systems and health outcomes. 16 Experts are worried about the increasing AMR among people in Bangladesh and India. The hospitals have become the hub for AMR in these countries. The expert assumed that the indiscriminate use of antibiotics during the peak of the COVID-19 pandemic might reduce the effectiveness of some antibiotics. 17 A study in a Bangladeshi COVID-19 dedicated hospital found that almost 80% of antibiotics for COVID-19 treatment were unnecessary, and about 70% of the prescribed medicines were antibiotics. 18 Indiscriminate antibiotic use for treating COVID-19 patients will potentially develop AMR that might be the next global health pandemic. 19 However, the COVID-19 mortality due to bacterial superinfection is more common than any other respiratory viral diseases. 20 Moreover, bacterial superinfection among hospitalized COVID-19 patients accelerates the disease progression and severity. The majority of COVID-19 patients are dying due to bacterial superinfection. 21 This condition urges antibiotic 2 Clinical Pathology therapy and ICU support for COVID-19 patients. 22 In that case, COVID-19 patients require antibiotics for proper management. But, there should have a balance between effective treatment and antimicrobial resistance. Therefore, physicians should follow antibiotic treatment protocols and guidelines extrapolated from international recommendations to manage bacterial superinfection in COVID-19 patients. Indiscriminate use of antibiotics without proper jurisdiction might create a future threat for another pandemic due to antibiotic resistance.

According to WHO, antibiotics become less effective against different strains of bacteria. As a result, many infections (eg, pneumonia, tuberculosis, and salmonellosis) are becoming difficult to treat. It warned that without prompt action to control the AMR, the world might face a "post-antibiotic" era where minor injuries and common infections might be lethal. 23 The major reasons for AMR across South and East Asia are the widespread accessibility of OTC antibiotics, lack of access to safe-pure drinking water, and inadequate sanitation fuel the spread of antibiotic-resistant "superbugs." 24 The people of South Asia usually take antibiotics to treat common colds which are viral infection, and mild diarrheal illness that fuels the spreading of AMR in the community. 25 As people are used to taking antibiotics in treating common colds, and the symptoms of COVID-19 resemble colds/flu, it exacerbates the overuse of antibiotics. Non-qualified healthcare workers and professional physicians in the informal healthcare sectors are prescribing antibiotics without proper jurisdiction. 25 Moreover, this phenomenon has increased significantly during the ongoing pandemic. Sometimes the over-prescription of antibiotics in developing countries is linked with aggressive and unethical marketing practices of the pharmaceutical companies. 26 Such irrational use of antibiotics is putting a superfluous financial burden on patients of these countries.

After the detection of highly muted variant omicron, the daily caseloads of novel coronavirus are increasing alarmingly in south Asian countries. 27 Several countries imposed different restrictions on regular activities to curb the transmission of this deadly variant. [28] [29] [30] [31] [32] [33] The impact of COVID-19 pandemic and its responses is tremendous on human life across the world. 8, [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] Therefore, along with COVID-19 vaccines, people in poor and developing countries might consume a myriad of antibiotics and other drugs without prescription during the COVID-19 waves. [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] The lessons learned from the previous pandemic should be implemented to regulate the usage of antibiotics in these countries. The pandemic phase of COVID-19 might be ended after the Omicron wave; however, the COVID-19 will continue. 56 Drug and healthcare regulatory authorities in several south Asian countries are trying to impose a control system regarding the indiscriminate use of antimicrobials and prevent AMR. However, we find their inadequate efforts in some countries due to the lack of proper guidelines, laws, logistics, and resources. South Asian countries require strong legislation and public awareness to address the threat due to AMR. In this regard, the healthcare authorities of south Asian countries can develop and implement country-specific antibiotic stewardship programs to assess and improve how antibiotics are prescribed by physicians and used by patients. The healthcare regulatory authorities should be more cautious in controlling the overuse of antibiotics in COVID-19 to prevent antibiotic resistance. The drug regulatory authorities should be more vigilant in implementing the antibiotic dispensing guidelines for outpatients. Also, they should take zero tolerance for antibiotic dispensing without prescription by the retailers. The healthcare authorities should monitor for rational use of antibiotics in hospitalized COVID-19 patients. Moreover, graduate pharmacists must be involved in the mainstream of the healthcare system to dispense antibiotics in a more controlled way. An electronic prescription tracking system can be adapted to dispense antibiotics to control the indiscriminate use of antibiotics. There should have a single computer database in which all the antibiotics that are dispensed are conveyed. Also, the authorities can set a maximum annual intake limit for antimicrobials. They should promote the prudent use of antibiotics in both hospitalized and non-hospitalized patients. We hope that the policymakers will recognize the seriousness of this issue and act promptly to reduce the irrational use of antibiotics during the devastating wave of the COVID-19 pandemic.

SD devised the study and wrote the first draft. MRI edited and revised the manuscript. Both the authors reviewed and approved the final submission.

https://orcid.org/0000-0001-7952-8147 Md. Rabiul Islam https://orcid.org/0000-0003-2820-3144

Detection of SARS-CoV-2 Omicron (B.1.1.529) variant has created panic among the people across the world: what should we do right now

Mucormycosis or black fungus infection is a new scare in South Asian countries during the COVID-19 pandemic: associated risk factors and preventive measures

Mucormycosis or black fungus is a new fright in India during covid-19 pandemic: associated risk factors and actionable items

Increments of gender-based violence amid COVID-19 in Bangladesh: a threat to global public health and women's health

Mental Health of children amid COVID-19 pandemic in Bangladesh: an Exploratory Observation

Impact of COVID-19 pandemic on mental health among general Bangladeshi population: a cross-sectional study

COVID-19 and child marriage in Bangladesh: emergency call to action

Social stigma and suicide in Bangladesh: the Covid-19 has worsened the situation

The second wave of COVID-19 pandemic in Bangladesh: an urgent call to save lives

WHO. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). WHO. Accessed

Bacterial and fungal coinfection in individuals with coronavirus: a rapid review to support COVID-19 antimicrobial prescribing

Coronavirus disease 2019, superinfections, and antimicrobial development: what can we expect?

Use of antimicrobials among suspected COVID-19 patients at selected hospitals, Bangladesh: findings from the first wave of COVID-19 pandemic

Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: an interrupted time series analysis

Antimicrobial consumption among hospitalized patients with COVID-19 in Pakistan

Understanding the social drivers of antibiotic use during COVID-19 in Bangladesh: implications for reduction of antimicrobial resistance

Rampant antibiotic use in India, Bangladesh worries experts

The Business Standard. 2021. Antibiotics unnecessarily used in 80% Covid treatments: study

Post COVID antimicrobial resistance threat in lower-and middleincome countries: Bangladesh. Front Public Health

Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2)

Factors associated with mortality in patients with COVID-19. A quantitative evidence synthesis of clinical and laboratory data

Deaths from bacterial pneumonia during 1918-19 influenza pandemic

Antibiotic-resistant infections in Bangladeshi kids deemed 'very worrying

Antibiotic-resistant bacteremia in young children hospitalized with pneumonia in Bangladesh is associated with a high mortality rate

Pathways of antibiotic use in Bangladesh: qualitative protocol for the PAUSE study

Qualitative insights into promotion of pharmaceutical products in Bangladesh: how ethical are the practices

Detection of highly muted coronavirus variant omicron (B.1.1.529) is triggering the alarm for South Asian countries: associated risk factors and preventive actions

Urgent call for mass immunization against coronavirus in Bangladesh

Omicron (B.1.1.529) variant of SARS-CoV-2: concerns, challenges, and recent updates

The SARS-CoV-2 omicron (B.1.1.529) variant and effectiveness of existing vaccines: what we know so far

The COVID-19 vaccination experience in Bangladesh: findings from a cross-sectional study

The massive attack of COVID-19 in India is a big concern for Bangladesh: the key focus should be given on the interconnection between the countries

New coronavirus variants are creating more challenges to global healthcare system: a brief report on the current knowledge

Increased suicidal behaviors among students during COVID-19 lockdowns: a concern of student's mental health in Bangladesh

Status of psychological health of students following the extended university closure in Bangladesh: results from a web-based cross-sectional study

Suicides among university students during the COVID-19 pandemic: Bangladeshi press reports

The SARS-CoV-2 omicron (B.1.1.529) variant and the re-emergence of COVID-19 in Europe: an alarm for Bangladesh

Factors associated with underprivileged E-Learning, session jam phobia, and the subsequent mental distress among students following the extended university closure in Bangladesh

Upsurge of dengue prevalence during the third wave of COVID-19 pandemic in Bangladesh: pouring gasoline to fire

Dataset concerning the mental health of healthcare professionals during COVID-19 pandemic in Bangladesh

Data set concerning the use of social networking sites and mental health problems among the young generation in Bangladesh

A nationwide dataset on the mental health of the Bangladeshi population due to the COVID-19 pandemic

The COVID-19 pandemic and suicidal behavior in Bangladesh: social stigma and discrimination are key areas to focus on

Effect of COVID-19 pandemic on mental health among Bangladeshi healthcare professionals: a cross-sectional study

Sexual violence against woman at quarantine center during coronavirus disease 2019 in Bangladesh: risk factors and recommendations

A cross-sectional study of COVID-19-related knowledge, risk perceptions, and preventive practices among pharmacy students in Bangladesh

Knowledge, perception, and willingness towards immunization among Bangladeshi population during COVID-19 vaccine rolling period

Urgent call for actionable measures to fight the current co-epidemic of dengue burden during the SARS-CoV-2 delta variant era in South-Asia

Recommendation and roadmap of mass vaccination against COVID-19 pandemic in Bangladesh as a lower-middle-income country (LMIC)

The "Delta Plus" COVID-19 variant has evolved to become the next potential variant of concern: mutation history and measures of prevention

Bangladesh reported delta variant of coronavirus among its citizen: Actionable items to tackle the potential massive third wave

Titer disparity of anti-Spike receptor binding domain SARS-CoV-2 antibody between vaccinated and naturally infected individuals

Nanomaterials and bioactive compounds against SARS-CoV-2

Clinical efficacy and safety of antiviral drugs in the extended use against COVID-19: what we know so far

The use of cow dung and urine to cure COVID-19 in India: a public health concern

The SARS-CoV-2 omicron wave is indicating the end of the pandemic phase but the COVID-19 will continue