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The COVID-19 disaster in India has left more than 30 million people infected with the virus and nearly 400,000 deaths, although experts fear the numbers are likely to be much higher. Meanwhile, another public health crisis has emerged with COVID-19: the widespread misuse of antibiotics.
During the first wave of COVID-19 in India, sales of antibiotics soared, suggesting the drugs were used to treat mild and moderate cases of COVID-19, according to research conducted by Washington University School of Medicine in Saint-Louis. Such use is considered inappropriate because antibiotics are only effective against bacterial infections, not viral infections such as COVID-19, and overuse increases the risk of drug-resistant infections.
“Antibiotic resistance is one of the biggest threats to global public health,” said lead author of the study, infectious disease specialist Sumanth Gandra, MD, associate professor of medicine and associate hospital epidemiologist at Barnes-Jewish Hospital. “Overuse of antibiotics decreases their ability to effectively treat minor injuries and common infections such as pneumonia, which means these conditions can become serious and life-threatening. Bacteria that have become resistant to antibiotics have no limits . They can spread to anyone in any country. “
The study, conducted in collaboration with McGill University in Canada, is published on July 1 in PLOS Medicine. Giorgia Sulis, MD, PhD, postdoctoral researcher at McGill, is the first author.
Antibiotics are drugs that save lives. However, left unchecked, germs learn to defy antibiotics designed to kill them while multiplying in strength. With more illnesses and deaths, antibiotic resistance leads to increased hospital stays and medical costs.
In high-income countries such as the US, UK and Canada, overall antibiotic use plunged in 2020, even during peaks in COVID-19. “This is because doctors in high-income countries generally do not prescribe antibiotics for mild and moderate cases of COVID-19,” Gandra explained. “The rise in India indicates that COVID-19 guidelines were not followed.”
Also worrisome are previous data analyzes concluding that COVID-19 cases and deaths in India also exceed official estimates. “In reality, the problem is probably much worse,” said Gandra, who also sits on a World Health Organization (WHO) committee focused on reducing antibiotic prescriptions in low- and middle-income countries. .
With nearly 1.4 billion inhabitants, India is the second most populous country in the world. “India is essential to study because it is the largest consumer of antibiotics in the world, and it is fundamentally an illustration of the abuse of antibiotics in low and middle income countries with health care practices. similar health, ”Gandra explained. “In general, these countries over-prescribe antibiotics in primary care settings. Therefore, we suspect that the pandemic has also stimulated the inappropriate use of antibiotics in many low- and middle-income countries.
Antibiotic use has increased despite Indian Ministry of Health and WHO guidelines calling for antibiotics for mild and moderate forms of COVID-19, which account for over 90% of cases. “Antibiotics should only be given to patients who develop secondary bacterial illnesses,” Gandra said. “This was not the case, indicating the need for policy changes in India, especially in light of the current crisis and the possibility of a devastating third wave.”
In India, an unregulated private sector accounts for 75% of healthcare and 90% of antibiotic sales, Gandra said. “This allows for an overprescription of antibiotics,” he said. “Low- and middle-income countries tend to ignore diagnostic tests for respiratory disease because most patients cannot afford it, so they are given antibiotics assuming their disease is bacterial. In the United States, however, patients who have a cold or a cough get tested for bacterial infections such as strep throat and only receive antibiotics if the tests are positive. “
To assess the impact of the pandemic on antibiotic use, the researchers analyzed monthly sales of all antibiotics in the private health sector in India from January 2018 to December 2020. The data came from an Indian branch office. from IQVIA, an American health information technology company.
Specifically, the researchers looked at the total sales volume of all antibiotics as well as the individual sales volume of azithromycin. The latter has been studied because some countries experienced an increase in sales of azithromycin early in the pandemic after observational studies suggested the antibiotic could help treat COVID-19 (later studies have disputed this affirmation).
The researchers determined that a total of 16.29 billion doses of antibiotics were sold in India in 2020, which is slightly lower than the amounts sold in 2018 and 2019. However, when the researchers focused on the adult doses, use increased from 72.6% in 2018 and 72.5% in 2019 to 76.8% in 2020.
Additionally, sales of azithromycin for adults in India increased from 4% in 2018 and 4.5% in 2019 to 5.9% in 2020. The study also showed a noticeable increase in sales of doxycycline and faropenem, two antibiotics commonly used to treat respiratory infections.
The researchers used previously published studies to compare the use of antibiotics in India with the use of these drugs in the United States and other high-income countries. In those countries, researchers found that adult antibiotic use declined significantly during the pandemic compared to such use in 2018 and 2019.
“It is essential to recognize that the use of antibiotics in high-income countries fell in 2020,” Gandra said. “People are isolated, schools and offices closed, and fewer people have contracted the flu and overall remained healthier from the pre-pandemic years. This has reduced the overall need for antibiotics. , as did the cancellation of dental procedures and outpatient surgeries.
“India also had restrictions and saw dramatic declines in malaria, dengue, chikungunya and other infections and infections usually treated with antibiotics,” he said. “Antibiotic use should have gone down, but it’s not. Not only that, but antibiotic use has increased along with the increase in COVID cases.”
After statistical adjustment for seasonality and mandatory lock-out periods, researchers estimated that COVID-19 likely contributed 216.4 million excess doses of antibiotics for adults and 38 million excess doses of azithromycin for adults. from June 2020 to September 2020, a peak period of four months. COVID-19 activity in India. “Our results indicate that almost everyone who has been diagnosed with COVID-19 has received an antibiotic in India,” Gandra said.
Azithromycin is an essential medicine for treating typhoid fever, non-typhoid salmonella and traveler’s diarrhea. “Unnecessary use will lead to resistance among the bacteria that cause these diseases,” Gandra said. “These infections are very common in India and other low and middle income countries… and azithromycin is the only effective oral treatment option available for typhoid fever in Pakistan.”
Researchers also studied hydroxychloroquine, an antimalarial drug touted as a potential treatment for COVID-19 earlier in the pandemic. In India, sales of the drug declined after the government issued an emergency order placing tighter restrictions on the sale of hydroxychloroquine. Gandra said the Indian government should seriously consider imposing similar restrictions on azithromycin and other antibiotics.
“The most recent wave in India is at least four times the first wave, and preliminary research shows a similar addiction to the use of antibiotics to treat mild and moderate cases of COVID-19,” he said. -he declares. “The medium and long-term consequences on bacterial resistance models are of great concern, highlighting the need for urgent antibiotic management measures, including mass vaccination. “
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