When the world gained control over COVID-19, infection control experts didn't get a reprieve. To the contrary, hospitals will need to confront the “pandemic lying in wait”: antibiotic resistance.

For decades, pathogens have been outwitting the antibiotics that revolutionized medicine in the 1940s. Well before COVID-19 emerged, drug-resistant "superbugs" were a global menace, costing 700,000 lives a year and straining hospital resources. Resistance had risen to over 70% of bacteria of bacteria — and to every antibiotic ever developed for use in the ICU setting. Infections once easily treated were requiring more toxic and complex regimens. None of this stopped when SARS-CoV-2 exploded.

“In the shadows of the COVID-19 pandemic,” Croatian scientists have warned, “there has been an ongoing antimicrobial resistance pandemic.”

Actually, the superbug crisis isn’t just “ongoing”; it’s primed to accelerate. Even more patients have taken antibiotics they don’t need. At the same time, those in dire need — patients with drug-resistant tuberculosis, for example — have seen their treatments interrupted. Research on new antibiotics, already lagging, has been halted.

In combination, these developments may well spawn new lethal variants and vexing nosocomial outbreaks. Without immediate action, common procedures — caesarean sections, knee replacements, cancer chemotherapy — will become riskier.

“We might be soon headed towards a post-antibiotic era, where a simple wound or a dental infection can be fatal,” warns Hatim Sati, M.D., a member of a World Health Organization (WHO) task force on antimicrobial resistance. “That is what’s at stake here.”

In response, hospitals must act on two fronts, dispensing antibiotics more judiciously while deploying more robust precautions against infection spread. Critical among these precautions is air disinfection.

Hand hygiene and surface cleaning remain important, but as the COVID-19 catastrophe has laid bare, all the antibacterial rub in the world won’t halt the transmission of an airborne pathogen.

Among the most worrisome superbugs, deemed “urgent” or “serious” threats by the U.S. Centers for Disease Control and Prevention (CDC), are Mycobacterium tuberculosis, Methicillin-resistant Staphylococcus aureus (MRSA), Carbapenem-resistant Acinetobacter and Clostridium difficile — all readily spread via air currents.

“The uncontrolled movement of air in and out of the hospital environment makes the bacterial persistence worse,” a research team noted in the Annals of Clinical Microbiology and Antimicrobials, “since these infectious microorganisms may spread easily through sneezing, coughing, talking and contact with hospital materials.”

Routine activities — mopping a floor, making a bed, cutting a bandage, removing a glove — can propel drug-resistant bacteria into the air. These aerosols can hover for hours and travel far.

Hospitals must be equipped to destroy airborne superbugs on a continual basis before these bacteria infiltrate open wounds, are inhaled by vulnerable patients, or mutate into strains that are impossible to treat.

How COVID-19 Has Amplified the Superbug Crisis

Antibiotics, of course, are worthless against viral infections, whether COVID-19, influenza or the common cold. Yet these drugs are routinely prescribed for patients infected by a virus, a practice that fuels antibiotic resistance.

Prior to the pandemic, over 30% of oral antibiotic prescriptions were unwarranted. Then COVID struck, and the percentage shot up.

Initially, doctors had trouble distinguishing COVID-19 from bacterial pneumonia, often prescribing antibiotics as a default. Or, antibiotics were prescribed for fear COVID patients might have bacterial co-infections. In most cases, the drugs were administered before tests confirmed, or ruled out bacterial infection.

This scenario was repeated on a global scale. Among COVID patients at 38 U.S. hospitals, 56% of patients received antibiotics early on of patients received antibiotics early on, though just 3.5% actually turned out to harbour bacterial infections. In Europe, 75% of severe COVID patients received antimicrobials, though only 15% had documented infections. Similar numbers were reported in Asia.

Rampant overprescribing of antibiotics to COVID patients has largely stopped, but the damage may already have been done.

What’s more, the pandemic-driven increase in telemedicine has increased antibiotic use among non-COVID patients. In the absence of physical exams or lab tests, doctors reflexively prescribe these drugs for a wide range of symptoms.

“Antimicrobial stewardship may be another casualty of the COVID-19 pandemic,” the Croatian team observed.

An additional casualty: the treatment of patients who actually require antibiotics. Microchips, sofas, and stoves aren’t the only commodities in short supply these days. Antibiotics and diagnostic tests have been scarce, too, what with manufacturing interrupted, stockpiles depleted, travel restricted, and medical clinics shuttered.

READ PART 2 of COVID-19 Amplified the Superbug Crisis. Hospitals Must Respond.