Could the COVID-19 pandemic aggravate antimicrobial resistance?

The coronavirus disease 2019 (COVID-19) pandemic reached Latin America later than other continents. The first case recorded in Brazil was on February 25, 2020, and 4 months later (June 20, 2020) there have been 1,032,913 confirmed cases including 48,954 deaths. These numbers have made Latin America the epicenter of the disease in the world (Fig 1) (Data extracted from COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University, June 20, 2020). Some points regarding COVID-19 in the world should be highlighted: (1) COVID-19 hospitalized patients at Intensive Care Units (ICU) share underlying diseases associated and risk factors to bacterial and fungal infections, such as corticosteroid therapy, chronic respiratory diseases, intubation/mechanical ventilation, and immunoinflammatory response (cytokine storm); (2) Secondary infections were found in 50% of COVID-19 mortalities. Therefore, bacterial and/or fungal secondary infections or coinfections are a probable factors that affect mortality of critically ill patients with COVID-19; (3) In hospital care the rate of antibiotics usage (94%-100%) was much higher than the reported incidence of secondary infection (10%-15%); (4) During the COVID-19 pandemic hospitals are overcrowded, with some medical centers reporting 50% more patients than normal. The increase in the number of invasive procedures associated with the use of antibiotics, steroidal anti-inflammatory and other immunomodulatory drugs and the overcrowding in health care settings may lead to an increase in Healthcare-Associated Infections. At the same time, there may be an increment in the severity of Healthcare-Associated Infections, resulting from the exposure of the patient's microbiota to these factors, through the selection, emerge and spread of resistance factors and more virulent microorganisms. In Brazil, these facts are particularly worrying. The overall prevalence of ICU-acquired infections in Brazilian hospitals is higher than reported in most European countries and the USA, with a greater proportion of infections caused by Gram-negative bacteria. Another point which should be considered is the telemedicine modality implemented to help in COVID-19 diagnosis and treatment. Previously the use of telemedicine to monitor antimicrobial stewardship showed better antibiotic selection and reductions in bacterial resistance. However, a study developed in a pediatric population reveals that over prescription of antibiotics is much more common in telemedicine than in face-to-face visits. Thereby, telemedicine antimicrobial prescription during the COVID-19 pandemic should be observed to avoid exacerbating antibiotic prescription. At moment, no antimicrobial stewardship interventions were described for COVID-19 in Brazil. Thus, microbiological data must necessarily be collected, mainly to identify pathogens, previously described or emerging, related to secondary infections in patients with Severe Acute Respiratory Syndrome. Today Brazil is the third country in terms of the absolute number of the deaths by COVID-19, and the Brazilian states with lower health resources have shown the highest mortality rate. Similarly, the number of hospitalizations has also increased. These observations alert us to the worsening of the antimicrobial resistance problem in Brazil, during and after the COVID-19 pandemic. Consequently, it is desirable that actions aimed at reducing mortality in patients with COVID-19, should take into account the worsening of the patient's clinical condition due to secondary infections caused by multi-resistant microorganisms. Therefore, epidemiological studies with antimicrobial surveillance systems that promote the production of quality evidence about antimicrobial intervention effectiveness in patients with COVID-19, especially in critically ill patients in intensive care units should be encouraged.