COVID-19 and Antibiotics

The 1918 Spanish Flu killed over 40 million people. Most of these deaths were not due to the virus itself, but due to secondary bacterial infections. When the body is faced with a virus, especially a new one, the immune system becomes overwhelmed. This allows for secondary infections such as bacterial pneumonia to set in, causing respiratory failure, sepsis and death. Antibiotics were not discovered until 1928, so many people perished at the hands of bacteria during the 1918 viral pandemic.

You may be thinking: What happened in 1918 is unfortunate, but we have antibiotics now, so we’re safe, right? 

Unfortunately, no. Far from it.

The crisis we faced in 1918 is not too far off from the crisis we are facing today with COVID-19. Although we now have antibiotics to treat secondary bacterial infections, our options are fading. The antibiotic pipeline is running dry and antibiotic resistance is growing with every passing day. Secondary bacterial infections are dangerous in and of themselves, but a growing number of these infections are now caused by antibiotic-resistant bacteria, also known as “superbugs.” 

If a COVID-19 patient is fortunate enough to avoid bacterial pneumonia prior to being on a ventilator, their chance of avoiding it significantly decreases after they are on one. Ventilator-associated bacterial pneumonia is the most common lethal infection found in intensive care patients. Plastic surfaces, such as the endotracheal tube placed down the throat and into the lungs of ventilated COVID-19 patients, are easily colonized by bacteria. These bacteria can then create a biofilm that is impenetrable by antibiotics, contributing to persistent infection.

Beyond this, being hospitalized for an extended period of time increases a patient’s risk of acquiring additional, non-respiratory related bacterial infections, such as urinary tract infections (UTIs). After a patient is sedated and ventilated, urinary catheterization is often required to measure urine output and other vitals. This significantly increases the patient’s risk of developing a UTI caused by E.coli and Klebsiella, bacteria that are becoming increasingly antibiotic-resistant. Left untreated by antibiotics, these infections can spread into the kidneys and bloodstream, leading to pyelonephritis (kidney infection), sepsis or death. Additionally, hospitalized patients are often connected to peripheral intravenous catheters (IVs) and central lines, increasing their risk of acquiring deadly skin infections caused by bacteria such as MRSA (Methicillin-resistant Staphylococcus aureus). Hospitalized patients fighting COVID-19 are extremely susceptible to these bacterial infections and antibiotics are crucial in saving their lives.

To address an area of potential confusion, there has been use of Azithromycin, a bacteriostatic antibiotic also known as “Zithromax” or “Z-Pak,” for the treatment of hospitalized patients with COVID-19. It has been administered in conjunction with the antimalarial drugs Chloroquine and Hydroxychloroquine, although these drugs have not been widely tested for the treatment of COVID-19. In addition to antibacterial coverage, certain studies indicate that Azithromycin may have potential immunomodulatory and anti-inflammatory effects, as well as anti-biofilm capabilities, which may help during a COVID-19 infection, but it should not be confused with antivirals or vaccines that directly treat or prevent viral infections.

While antibiotics are keeping us afloat during this pandemic, the judicious use of this medication is more crucial than ever. Ramping up since 2014, antibiotic stewardship programs have been established across the U.S. to curb bacterial resistance and promote appropriate antibiotic use. These programs have been largely focused within hospitals and have found moderate levels of success, but over 60% of U.S. antibiotic prescriptions are given in the ambulatory setting such as outpatient, primary and urgent care centers. Within these settings, upper respiratory tract infections (URTIs) are notorious for contributing to inappropriate antibiotic prescriptions. The Centers for Disease Control reports that over 50% of outpatient antibiotic prescriptions for URTI are unnecessary, as most respiratory infections are viral and self-limiting. The respiratory nature of COVID-19, combined with this period of heightened anxiety, may significantly increase this rate of inappropriate antibiotic prescriptions. 

COVID-19 can be envisioned as a train that’s running straight through our front yard. It’s loud, it’s wreaking havoc on societies across the globe, and it’s perpetually on everyone’s mind. We will surely breathe a collective sigh of relief after this pandemic has passed, but our fight to protect public health will be far from over. We must allocate some of our attention to the looming antibiotic resistance train that is headed straight for our front door. This train threatens to splinter the very core of modern medicine and leave nothing but destruction in its wake. Unlike COVID-19, though, this train is quiet. It’s a slow burn. It’s the perfect storm for a society that’s easily preoccupied with the immediate. For the average person, the distant rumblings of this train likely go unnoticed, but if you listen closely, you can hear it. You can hear it in the story of the Seattle man who lost his leg due to antibiotic resistant bacteria. You can hear it in the death of the Nevada woman whose urinary tract infection was resistant to all known antibiotics. Perhaps this train is not as far off as we initially thought. Perhaps the COVID-19 pandemic is unveiling this dark reality as it ambles closer and closer to our home. The time for tuning out these distant rumblings is no longer. The time for action is now. We—patients, physicians, policy makers and scientists—must join together to combat antibiotic resistance. This will be a group effort, and if the COVID-19 pandemic has taught us anything, the stakes for collaboration could not be higher.