COVID-19 aggravates antibiotic misuse in India, study finds
Sales of antibiotics soar as threat of drug-resistant bacteria worsens


Date:
July 1, 2021
Source:
Washington University in St. Louis
Summary:
Antibiotic sales soared during India's first surge of COVID-19,
suggesting that the drugs were inappropriately used to treat mild
and moderate COVID-19 infections, according to new research. The
excessive usage is especially concerning because antibiotic overuse
increases the risk for drug-resistant infections -- not just in
India, but worldwide.



FULL STORY ==========================================================================
The COVID-19 catastrophe in India has resulted in more than 30 million
people infected with the virus and nearly 400,000 deaths, though experts
are concerned that the figures most likely are much higher. Meanwhile,
another public health crisis has emerged along with COVID-19: the
widespread misuse of antibiotics.


========================================================================== During India's first surge of COVID-19, antibiotic sales soared,
suggesting the drugs were used to treat mild and moderate cases of
COVID-19, according to research led by Washington University School of
Medicine in St. 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 for drug-resistant infections.

"Antibiotic resistance is one of the greatest threats to global public
health," said the study's senior author, infectious diseases specialist
Sumanth Gandra, MD, an associate professor of medicine and an associate hospital epidemiologist at Barnes-Jewish Hospital. "Overuse of antibiotics lessens their ability to effectively treat minor injuries and common
infections such as pneumonia, which means that these conditions can become serious and deadly. Bacteria that have become resistant to antibiotics
don't have boundaries. They can spread to any person in any country."
The study, conducted in collaboration with McGill University in Canada, is published July 1 in PLOS Medicine. Giorgia Sulis, MD, PhD, a postdoctoral researcher at McGill, is the first author.

Antibiotics are life-saving medications. However, unchecked, germs learn
to defy the antibiotics designed to kill them while also multiplying
in force.

Along with more illnesses and deaths, antibiotic resistance leads to
increased hospital stays and medical costs.

In high-income countries such as the United States, United Kingdom and
Canada, overall antibiotic use plunged in 2020, even during COVID-19
peaks. "This is because physicians in high-income countries generally did
not prescribe antibiotics for mild and moderate COVID-19 cases," Gandra explained. "The uptick in India indicates that COVID-19 guidelines were
not followed." Also worrisome are prior data analyses concluding that
COVID-19 cases and deaths in India surpass the official estimates. "In
reality, the problem is likely much worse," said Gandra, who also serves
on a World Health Organization (WHO) committee focused on reducing
antibiotic prescriptions in low- and middle-income countries.



==========================================================================
With nearly 1.4 billion people, India is the world's second most populous country. "India is essential to study because it is the largest consumer
of antibiotics in the world, and it's basically a poster child for
antibiotic misuse in low- and middle-income countries with similar
health-care practices," Gandra explained. "In general, these countries excessively prescribe antibiotics in primary care settings. Therefore,
we suspect the pandemic has also spurred inappropriate antibiotic use
in many low- and middle-income countries." Antibiotic use increased
despite guidelines from the Indian Health Ministry and WHO urging against antibiotics for mild and moderate forms of COVID-19, which account for
more than 90% of the 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 health care
and 90% of antibiotic sales, Gandra said. "This allows for antibiotic overprescription," he said. "Low- and middle-income countries tend to
skip diagnostic testing for respiratory illnesses because most patients
cannot afford it, so they receive antibiotics under the assumption that
their illness is bacterial. In the U.S., however, patients with a cold
or a cough usually undergo testing for bacterial infections such as
strep throat and only receive antibiotics if the tests are positive."
To assess the pandemic's impact on antibiotic use, researchers analyzed
monthly sales of all antibiotics in India's private health sector from
January 2018 through December 2020. The data came from an Indian branch
of IQVIA, a U.S.- based health information technology company.

Specifically, researchers examined the total sales volume of all
antibiotics as well as the individual sales volume for azithromycin. The
latter was studied because some countries experienced a spike in
azithromycin sales early in the pandemic after observational studies
suggested the antibiotic could help treat COVID-19 (subsequent studies
disputed the claim).



==========================================================================
The researchers determined that a total of 16.29 billion doses of
antibiotics were sold in India in 2020, which is slightly less than the
amounts sold in 2018 and in 2019. However, when researchers focused on
adult doses, usage 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 notable increases in the sales of doxycycline and faropenem, two antibiotics
commonly used to treat respiratory infections.

The researchers used previously published studies to compare India's
antibiotic use with use of such drugs in the U.S. and other high-income countries. In those countries, the researchers found that adult antibiotic
use decreased drastically during the pandemic compared with such use in
2018 and 2019.

"It's critical to acknowledge that antibiotic use in high-income countries plummeted in 2020," Gandra said. "People isolated, schools and offices
closed, and fewer people got the flu and, overall, stayed healthier
compared with the pre-pandemic years. This reduced the overall need for antibiotics, as did canceling dental procedures and outpatient surgeries.

"India also had restrictions and experienced dramatic decreases in
malaria, dengue, chikungunya and other and infections typically treated
with antibiotics," he said. "Antibiotic use should have gone down,
but it didn't.

Not only that but antibiotic use increased along with the rise of COVID
cases." After statistically adjusting for seasonality and mandatory
lockdown periods, researchers estimated that COVID-19 likely contributed
to 216.4 million excess doses of antibiotics for adults and 38 million
excess doses of azithromycin for adults from June 2020 through September
2020, a four-month period of peak COVID-19 activity in India. "Our results indicate that almost everybody who was diagnosed with COVID-19 received
an antibiotic in India," Gandra said.

Azithromycin is a vital drug for treating typhoid fever, non-typhoidal Salmonella and traveler's diarrhea. "Unnecessary use will lead to
resistance among the bacteria that cause these illnesses," Gandra
said. "These infections are highly prevalent 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 anti-malarial drug touted as a potential treatment for COVID-19
earlier in the pandemic. In India, sales of the drug decreased after the government issued an emergency order imposing stronger restrictions on
the sale of hydroxychloroquine. Gandra said the Indian government should strongly consider mandating similar restrictions for azithromycin and
other antibiotics.

"The most recent wave in India is at least four times the first
wave, and preliminary research shows a similar reliance on
using antibiotics to treat mild and moderate COVID-19 cases,"
he said. "The medium- and long-term consequences on bacterial
resistance patterns are highly concerning, highlighting the need for
urgent antibiotic stewardship measures, including mass vaccination." ========================================================================== Story Source: Materials provided by
Washington_University_in_St._Louis. Original written by Kristina
Sauerwein. Note: Content may be edited for style and length.


========================================================================== Journal Reference:
1. Giorgia Sulis, Brice Batomen, Anita Kotwani, Madhukar Pai, Sumanth
Gandra. Sales of antibiotics and hydroxychloroquine in India during
the COVID-19 epidemic: An interrupted time series analysis. PLOS
Medicine, July 1, 2021; DOI: 10.1371/journal.pmed.1003682 ==========================================================================

Link to news story: https://www.sciencedaily.com/releases/2021/07/210701140624.htm

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