While the world has spent the last two years laser-focused on the COVID pandemic, another public health threat is still lurking in the shadows: the rise of antibiotic-resistant bacteria. Antimicrobial resistance (AMR) has been recognized since the early 1900s, yet rigorous research over the past decade has illuminated the magnitude of the threat and its implications for future infection control. More than 35 thousand patients die from antibacterial resistance every year, and antibiotic-resistant infections exceed 2.8 million annually, according to a CDC report released prior to the COVID pandemic.

Meet the superbugs.

Four bacteria identified by a 2019 CDC report as threats requiring urgent and aggressive action include carbapenem-resistant Acinetobacter and Enterobacteriaceae, Clostridioides difficile, and drug-resistant Neisseria gonorrhea. Treatment options for infections caused by carbapenem-resistant Acinetobacter and Enterobacteriaceae and drug-resistant Neisseria are limited to more toxic or less efficacious antibiotics. The CDC report also found that C. difficile causes nearly 224,000 cases per year, resulting in more than 12,800 deaths. The CDC has listed numerous other bacteria as serious or concerning threats, such as drug-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus, and multidrug-resistant Pseudomonas aeruginosa.

Has the COVID pandemic altered the course of bacterial resistance?

During some phases of the current pandemic, many people experienced a reduction in physical exposure to infection sources due to stay-at-home orders, social distancing, and masking. Conversely, more patients than usual were hospitalized and potentially exposed to health care-associated infections. According to one report, throughout 2020, outpatient antibiotic prescriptions in the U.S. decreased significantly, especially those related to respiratory infections, surgical prophylaxis, and pediatric indications. Urgent care centers at one academic medical center that transitioned care to telemedicine in 2020 reported a sustained decrease in antibiotic prescribing for respiratory infections, despite stable prescribing for nonrespiratory conditions such as gastrointestinal, genitourinary, and skin infections. However, in that same year, three-fourths of COVID-19 patients received antibiotics — despite an estimated bacterial coinfection rate of less than 9 percent — according to a report of more than 30 thousand patients with lab-confirmed COVID. While it will take time to assess all the pandemic-associated changes in antibiotic prescribing, there is strong encouragement from infectious disease experts to continue the recent trend of reduced inappropriate antibiotic prescribing for respiratory infections.

The pace of new antibacterial agents is lagging.

Here are steps clinicians can take to safeguard the ability to treat bacterial infections well into the future:

1. Prevent infections. The COVID pandemic has significantly affected rates of preventive vaccinations in multiple populations. Pneumonia caused by MRSA and other bacteria is a leading cause of death in influenza patients, and influenza vaccination may decrease the risk of deadly superinfection. Encourage routine and catch-up vaccinations as recommended by the CDC.

2. Manage viral infections without antibacterials. The CDC concluded that 30 percent of antibiotic prescriptions in 2016 were unnecessary. Acknowledge patient symptoms, offer symptom relief options, and educate about the risks of inappropriate antibiotic use. Follow specialty society guidance for the treatment of viral infections.

3. Tailor the spectrum. Overly broad-spectrum antibiotics unnecessarily increase the risk for antibiotic resistance. In institutional settings, use the most current local antibiotic susceptibility data available to guide decision-making. If cultures are sent, narrow the spectrum to cover identified bacteria and susceptibility results.

4. Limit antibiotic durations. CDC and other infectious disease experts’ guidance has adjusted the duration of therapy for common bacterial infections in recent years. Follow specialty society guidance for antibiotic treatment durations.

5. Support antibiotic stewardship and infection control programs. Increased scrutiny around infection control procedures for COVID may have a carryover benefit in reducing health care-associated bacterial infections as well. Increased attention to antibiotic stewardship principles may positively impact patient outcomes, such as decreasing rates of difficile infections.

The current pandemic is an opportunity for clinicians to reset appropriate antibiotic prescribing for bacterial infections. A multi-pronged approach, including managing patient expectations around antibiotic prescriptions, will pay significant dividends to the future of bacterial infection control.

Anne Meneghetti is an internal medicine physician and health care executive.

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