Antibiotic resistance posed a threat to our lives long before COVID-19, and experts now worry that misuse and overuse of antibiotics during the pandemic may have exacerbated the rise of so-called "superbugs"—bacteria that are extremely difficult or impossible to treat with existing drugs.

Antimicrobial resistance (AMR) has been described as one of "the most urgent health threats of our time" by Dr Bounkong Syhavong, president of the 72nd World Health Assembly, and was named a priority for global public health for 2020 by the World Health Organization (WHO).

The global impact of AMR is estimated to have caused 1.27 million deaths in 2019 – more deaths than HIV/AIDS or malaria, according to a comprehensive analysis by the Lancet published in January.

In the United States alone, antibiotic-resistant superbugs cause more than 2.8 million infections and over 35,000 deaths annually, the country's Centers for Disease Control and Prevention (CDC) data reveals.

How COVID-19 may be making the problem worse

While bacterial resistance is a natural occurrence, overuse and misuse of antibiotics during the early stage of the pandemic may have made the problem worse, though it takes time for the impact to become evident. 

A majority of COVID-19 hospital admissions were prescribed antibiotics for symptoms – cough, fever, shortness of breath and X-rays revealing lung inflammation – that were in other times often diagnosed as bacterial pneumonia.

According to a study by the Pew Charitable Trusts, more than half of the nearly 5,000 patients in the U.S. hospitalized from COVID-19 between February and July 2020 received antibiotics, and 96 percent of the cases were given a first antibiotic before a bacterial infection was even confirmed. 

"So it appears that physicians frequently prescribed antibiotics empirically," authors of the study noted.

"When you deal with uncertainty, you err on the side of the prescribing, which is not necessarily the right thing to do," Jacqueline Bork, MD, an infectious disease physician at Baltimore-based University of Maryland Medical Center, told National Geographic. "Many of us were probably overprescribing a good amount of antibiotics. But without a firm understanding of what we were dealing with, we did the best we could at the time."

Drugs such as Ivermectin, Azithromycin and Chloroquine were widely prescribed by physicians and even encouraged by some regions, particularly in rural areas where access to diagnostic tests like X-rays were in short supply, let alone confirmation on the cause to be bacterial, fungal or viral.  

However, these are broad-spectrum antibiotics that destroy several types of bacteria and have no benefit against viruses like SARS-CoV-2, although several studies suggest less than 20 percent of fungal and bacterial co-infections were evident among COVID-19 patients.

What's worse was that when patients weren't able to consult doctors as medical resources were largely occupied by severely-ill patients, people self-medicated with antibiotics as a preventative measure. "The COVID-19-stressed ICUs relaxed stewardship" and might have encouraged antibiotic resistance, according to David Livermore, professor in medical microbiology at the Norwich Medical School at the University of East Anglia, who's also the author of the article "Antibiotic resistance during and beyond COVID-19."

'The damage is done'

A 2020 survey conducted by the WHO worldwide showed that 35 of 56 countries reported an increase in antibiotic prescriptions during the pandemic. 

While the storm of superbugs is yet to be detected, "the damage is done," said Pilar Ramon-Pardo, regional adviser on antimicrobial resistance at the Pan American Health Organization (PAHO).

In addition, incentives for new drug development are low, according to Muhammad Zaman, professor of biomedical engineering at Boston University.

There have been few new antibiotics in drug company pipelines as they tend to be much less profitable than other therapeutics for chronic diseases. The new drugs are also likely to encounter drug resistance fairly quickly, making investment in innovation less lucrative.

"Throughout the pandemic we have taken the power of antimicrobials for granted," said PAHO director Carissa Etienne, adding that it may take months or years before the full impact of their misuse and overuse becomes evident.

"Just as we were able to channel our collective capacity to develop diagnostics and vaccines for COVID in record time, we need commitment and collaboration to develop new and affordable antimicrobials," Etienne said.