CDC Doc Addresses Today's Pandemic and the Next

Arjun Srinivasan, MD (Captain, USPHS)


November 23, 2020

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On July 1, 2020, when I began a rotation on the infectious disease consult service at the Veterans Administration Hospital in Atlanta, we had three patients with COVID-19. Just days later, we had about 30.

Arjun Srinivasan, MD (Captain, USPHS)

In "normal times," my job at the Centers for Disease Control and Prevention (CDC) focuses on preventing healthcare-associated and antibiotic-resistant infections — issues where we know what works: consistent infection prevention and improved antibiotic stewardship. Implementation of these easy-sounding principles is challenging in the best of times. The world we live in now as a result of the pandemic underscores the fragility of our systems to combat infectious disease threats, whether they be SARS-CoV-2 or the frightening infections caused by antibiotic-resistant pathogens.

I returned to CDC after my time on service with one very clear understanding: We aren't going back to normal times. Asymptomatic and presymptomatic people are spreading SARS-CoV-2. This requires that we shift our focus in infection control to recognizing the risk associated with undiagnosed infection. We must continually act with caution. We must pair the principles of infection control and antibiotic stewardship with the need to protect patients and ourselves. And we must maintain this focus indefinitely, because the global threat of antibiotic resistance is bubbling just under the surface, and it's not going away.

Here's how I see the impact of COVID-19 on antibiotic resistance in this new normal.

The threat of antibiotic resistance is as real as COVID-19. We at the CDC regularly hear from healthcare providers that they don't believe they are contributing to antibiotic resistance or that it is not a problem for their patient population. In fact, primary care physicians in recent Pew focus groups saw it largely as a hospital issue. Like COVID-19, however, resistant pathogens have been found in every US state. People colonized with these pathogens are spreading resistance silently across our communities, spiking infections overnight in hospitals with few or limited treatment options. This "not my problem" mentality toward antibiotic resistance is now, more than ever, an unacceptable approach to modern medicine.

The good news is that we've seen some progress combating resistance in hospitals. Just last year, CDC reported 27% fewer antibiotic-resistant infections in hospitals from 2012 to 2017. We know what works, but we must recognize antibiotic resistance as an ever-looming threat that requires ongoing action.

Antibiotic resistance won't always be in the news, but it has been and will continue to be a part of our new normal.

COVID-19 prevention also protects from antibiotic-resistant infections. At the point where some hospitals may resume less COVID-focused operations, we cannot let our guard down. The infection control mentality we've adopted in the pandemic will save lives from antibiotic-resistant infections.

Many of us were expecting a dramatic increase in secondary infections because of the fragility or susceptibility of patients with SARS-CoV-2 infections. But data from more than 150 hospitals covering 14,000 discharges indicate that patients with COVID-19 did not have more bacterial and fungal infections than patients with influenza-like illness overall — especially in the community (Figure 1).

However, in hospitals specifically, the COVID-19 pandemic can create a perfect storm for antibiotic-resistant infections. Prolonged lengths of stay; crowding; and infection control challenges, such as training gaps and shortages in personal protective equipment, all contribute. For example, infections caused by extended-spectrum beta-lactamase–producing Enterobacteriaceae occurred far more often in patients with COVID-19 this year than those with influenza-like illness last year.

That said, outside of a handful of antibiotic resistance outbreaks in COVID units, we have not seen an increase in antibiotic-resistant infections this year. That could reflect ongoing efforts in infection control and antibiotic stewardship.

Figure 1. Hospital data on antibiotic-resistant infection from 14,000 discharges. The data show that patients with COVID-19 this year did not have more bacterial or fungal infections than patients with influenza-like illness last year. CRAB = carbapenem-resistant Acinetobacter baumannii; CRE = carbapenem-resistant Enterobacteriaceae; CRPA = carbapenem-resistant Pseudomonas aeruginosa; ESBL = extended-spectrum beta-lactamase–producing Enterobacteriaceae; MRSA = methicillin-resistant Staphylococcus aureus; VRE = vancomycin-resistant enterococcus.

The COVID-19 pandemic is a critical moment for fighting antibiotic resistance. November 2020 — the middle of cold and flu season and during a global pandemic — could be a pivotal moment in our fight against antibiotic resistance. It'd be easy for healthcare providers to reach for antibiotics despite knowing they're not effective against the virus. I experienced this pressure firsthand doing infectious disease consults during a surge in COVID cases. We so badly want to help people feel better faster.

Early in the pandemic, many hospitalized patients were treated with antibiotic agents recommended for community-acquired pneumonia; ceftriaxone and azithromycin prescribing were up at least 22% and 35%, respectively (Figure 2). Since this initial spike in hospital antibiotic use in March and April, data from more than 1100 hospitals representing 2 million discharges show us that prescribing went back to baseline or slightly below by May and June. This does not mean that we don't still have more work to do. A recent report from CDC shows that prescribing rates are still way too high.

Figure 2. Ceftriaxone and azithromycin prescribing in 2019 and 2020.

Under normal circumstances, patient care is complex and the demands on our time are numerous. Those demands are even greater now. Given that, this is a good time to focus our efforts on situations with the highest potential return on investment. Data have consistently shown respiratory infections to be a high-yield target across all healthcare settings, and that coincides perfectly with the upcoming respiratory disease season.

November 18-24 is US Antibiotic Awareness Week, when CDC shares a variety of stewardship resources. The challenges antibiotics presented before COVID-19 still exist in the new normal. "The right diagnosis, drug, dose, duration" mantra is as critical now as it ever was, especially as our hospitalized patients face the triple threat of COVID-19, influenza, and antibiotic-resistant infections.

This fall, we can all improve care by ensuring that an antibiotic is in fact needed for an individual patient with a respiratory infection. When needed, we must ensure that we're using the right drug for the right duration, remembering that less is often more when it comes to antibiotic duration. Our prescribing this year can help continue to bend the curve of antibiotic resistance trends in years to come.

At the end of my infectious disease consult service rotation at the Veterans Administration, I was elated to see that despite the incredible increase in patients and pace of care brought on by the pandemic, my colleagues and I remained diligent in our infection prevention and antibiotic stewardship practices. Our consistency and resilience while we protect patients and ourselves made a difference for our patients, as I know your efforts have for yours.

As we make the transition to our new normal, please know that CDC is fighting with you. Working with sister agencies, we're building data tools you need. We're embarking on research to understand the long-term effects of COVID-19 on antibiotic resistance, both domestically and globally. In the next 5 years, we're working to double our investments in your state and local health departments to ensure you have top-notch surveillance, epidemiology, and laboratory support. We're devoting ourselves to help ensure our healthcare system can support resilient infection control and antibiotic use programs. There will be additional challenges ahead as new threats, including antibiotic-resistant ones, emerge. We're committed to you and every healthcare provider to ensure we're ready to meet those threats to better protect patients and promote safer, quality care.

Thank you for fighting today's pandemic and preventing the next.

Arjun Srinivasan, MD (CAPT, USPHS) is the Associate Director for Healthcare Associated Infection Prevention Programs, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases at the CDC.

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