AMR WEEK 2020 in the COVID-19 era "Antimicrobials: handle with care".

World Antimicrobial Awareness Week (WAAW) is held every year from 18 to 24 November, with the aim of raising awareness of antimicrobial resistance (AMR) and encouraging best practice in the use of antibiotics among the general population, healthcare professionals and policy makers, with the ultimate goal of preventing the further emergence and spread of drug-resistant infections. This year's WAAW 2020 has chosen the slogan "Antimicrobials: handle with care" as its leitmotif.

The pandemic caused by SARS-COV-2, which has brought public health worldwide to its knees, developed at a time when there was already a major threat to public health: antibiotic resistance. In fact, Antimicrobial resistance (AMR), is today one of the public health problems with the biggest impact on both human and veterinary health. As is well known, AMR is a natural phenomenon determined by the adaptability of certain micro-organisms, which acquire the ability to survive or grow in the presence of a concentration of an antimicrobial agent, which is generally sufficient to inhibit or kill micro-organisms of the same species.

This phenomenon may be intrinsic to one microbial species as opposed to others, it may result from spontaneous mutations of some micro-organisms and may be transferred from these to others of different species. In any case, in the presence of antimicrobials, resistant microorganisms have a selective advantage over all others. This advantage allows them to multiply, to prevail over others and, in the case of pathogenic micro-organisms, to harm the host with the occurrence of a disease that is difficult to treat, or indeed untreatable, if no other effective antimicrobials are available.

Globally, it is estimated that around 700,000 people die from bacterial infections every year and it is estimated that by 2050 this could rise to a total of 10 million deaths per year surpassing cancer deaths, estimated at 8.2 million in the same year. In Europe, the resistance of bacteria to antibiotics causes at least 25,000 deaths per year, a figure that is set to increase tenfold within 35 years. he economic consequences of this phenomenon are staggering: it is estimated that the need to use second- or third-line antibiotics for the treatment of numerous infections (sometimes requiring hospitalisation) already entails additional costs amounting to approximately € 1.5 billion each year for the hospitals of the European Union .

It is furthermore necessary to pay particular attention to this enormous health problem in the context of the SARS-COV-2 pandemic, in which this viral infection is further aggravating the health and economic conditions of the entire planet. Indeed, as described by the authors of a paper published in Clinical Infectious Diseases ("COVID-19, superinfections and antimicrobial development: What can we expect?" see Attachment 1) at the end of Phase I in China, secondary infections were reported in 5% - 27% of adults hospitalised with SARS-CoV-2 infection in several hospitals in Wuhan, ranging from 13.5% to 44% of patients diagnosed with COVID-19 in intensive care wards, and up to 50% - 100% of those who had died.

The most common type of infection among these patients was bacterial or fungal pneumonia, but urinary tract infections and sepsis have also been observed. The microorganisms isolated included germs with different degrees of resistance: from Pan-drug resistant (PDR) - Acinetobacter baumannii, carbapenemase-producing Klebsiella pneumoniae (KPC) to Extended spectrum beta lactamase producing (ESBL) germs such as Pseudomonas aeruginosa, Enterobacter cloacae, Serratia marcescens, Aspergillus fumigatus, Aspergillus flavus, Candida albicans and Candida glabrata. The median time between admittance to intensive care and the onset of secondary infection among patients in 2 hospitals was 10-12 days and 17 days after the first COVID-19 symptoms, while the median time to death was 19 days, suggesting that superinfections were often terminal events.

Other publications confirm the problem as the pandemic spread beyond China: in March 2020, for example, in 2 hospitals in New York City, bacteremia was found in 6% of all COVID-19 patients admitted and 12% of those on mechanical ventilation. Also in the first European report, one of three patients with severe COVID-19 in France was diagnosed with co-infection by secondary A. baumannii and A. flavus.

Finally, in a report of 552 hospitals in 30 Chinese provinces, 58% of patients were treated with antibiotics, a figure that reached 80% in COVID-19 patients in critical condition in Chinese intensive care units. Empirical antibiotic therapy was likely widespread as 25% to 70% of severe patients had evidence of sepsis and it was very difficult to exclude bacterial or fungal superinfections based on signs and symptoms, physical findings, radiographic abnormalities and laboratory results. This phenomenon is well known in viral epidemics/pandemics so much so that for example influenza vaccination is considered one of the cornerstones of AMR prevention precisely because it limits the use of inappropriate antimicrobial therapy in case of viral infection.

Thus, fears that a percentage of patients with severe COVID-19 symptoms and consequent complications will also develop superinfections from antibiotic-resistant pathogens are certainly plausible and well-founded. Moreover, as highlighted in the study published in BMJ on 18th May 2020 entitled "How covid-19 is accelerating the threat of antimicrobial resistance" (Attachment 2), health responses to the new coronavirus could exacerbate the threat of antibiotic resistance, precisely because of the increase in antibiotic therapies.

Another recent study entitled "Multidrug resistant infections in the COVID-19 era, a framework for considering the potential impact" (Attachment 3) analyses some factors that could have, in particular cases and conditions, a negative or positive impact on the transmission of multi-drug resistant organisms (MDRO). The study describes the potential impact of these various factors to provide a conceptual framework and determine their overall weight as summarised in this table extracted from the article.



Infection prevention and control practices and use of PPE

PPE shortage due to the rapid increase in the number of people admitted with COVID-19

Isolation of patients with COVID-19, application of advanced standard precautions (hand hygiene policy and respiratory hygiene), use of PPE (if available) and appropriate environmental disinfection procedures

Hospital overcrowding

The need for large-scale medical care exceeds the availability of hospital beds, resulting in overcrowded facilities

The lack of beds in the intensive care units has led to the development of new facilities both inside and outside the existing intensive care hospital facilities, many of which with existing colonisation and MDRO

Healthcare workers

High staff sickness rates and nosocomial acquisition of COVID-19, resulting in a low ratio of health workers to patients

ICUs designed for COVID-19 with dedicated healthcare workers may have reduced cross transmission of nosocomial infections

Demographic characteristics of COVID-19 patients

Elderly patients with comorbidity require prolonged hospitalisation with mechanical ventilation support and high use of broad-spectrum antibiotics

Lower rates of hospitalisation from long-term care facilities can lead to fewer transmission cycles between long-term care facilities and hospitals

Table 1: Potential impact of coronavirus 2019 disease (COVID-19) on hospital transmission of multi-drug resistant organisms (MDROs)

It is easy to understand how the above has triggered an important social alarm that is particularly problematic and difficult to manage.

To raise awareness of the prudent use of antimicrobials and, at the same time identifying this problem as a national health emergency, the Ministry of Health has implemented a targeted action through the organisation of the Piano Nazionale di Contrasto all’antimicrobico-resistenza (National Plan to Combat Antimicrobial Resistance -PNCAR) 2017-2020. Its indications aimed at limiting this serious phenomenon, and in conjunction with One Health, which acts at the veterinary, environmental, clinical and pharmaceutical level, include many initiatives promoted throughout Italy and also by the Region of Sardinia during the World Antibiotic Resistance Week. All of this against the backdrop of the severe pressure placed on global health by the current pandemic.

On the occasion of this important anniversary,, inviting users to reflect on the importance of this phenomenon, reports the main activities carried out on the regional, national and international scene.

In particular, the Region of Sardinia joined this important celebration through the implementation of a communication campaign which was presented on 15 October in Cagliari by the Councillor for Health, Mario Nieddu, the General Manager of the Cagliari AOU, Giorgio Sorrentino, and Stefano Sardara, President of Dinamo Sassari, testimonial of the campaign with coach Gianmarco Pozzecco and team playmaker Marco Spissu. This initiative, the result of work shared by the entire Public Health Department of our region, aims to offer an important message for the appropriate use of antimicrobial drugs, especially in these uncertain times.

On the national and international scene, there are also numerous social media campaigns implemented for this occasion bearing the leitmotif: "Antimicrobials: handle with care", in the hope that the explosion of the digital age, in this phase of physical distancing, will allow Healthcare Operators to reach as many users as possible in order to raise awareness and share this important message for health protection.

Attached is the Photo Gallery of the main posters and iconographies created for the occasion.

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Other Sources Network Bibliotecario Sanitario Toscano (
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