It’s the year 2012. I am in my second year of Bachelor’s degree in CBM (Chemistry, Botany, Microbiology) at the JC Road campus of Jain (deemed-to-be) University, Bangalore. The college building is a seven-floor sleek tower, and our class is being held in one of the cuboid classrooms on the fifth floor. I am late for the morning class yet again, so let’s call it a routine rather than an anomaly. Thankfully, the professor, Dr Vijayalakshmi Pradeep, lets me in. As I settle down, in our class of twenty-something twenty somethings, she finishes taking our attendance and gets up. She walks between two rows of seats, and after reaching the middle, declares, “Today, my dear delinquents, we are going to learn about antibiotics.”

She goes on to narrate a story about the accidental discovery of the first antibiotic, penicillin, by Alexander Fleming, and the subsequent gold rush in antibiotic discovery that followed in the next few decades, which produced most of the antibiotics we still use. During the lecture, in her almost spellbinding narrative style, she also highlights the ease with which many people walk up to a pharmacist and demand antibiotics at the slightest sight of discomfort, as if buying candies for their children. The dialogue she used in order to point at the everydayness of this antibiotic misuse, “Cheta, one strip Amox kodi!” referring to people asking pharmacists for a strip of amoxicillin, still seems fresh in my mind, as if the class happened just yesterday. This is perhaps because I have heard different renditions of the line in many pharmacies, across different cities, each of which reminds me of that dialogue. Even within the IITJ campus, when a student visits the Institute’s primary health centre with any sort of infection, be it bacterial or viral, they are mostly prescribed with a broad-range antibiotic course for 5-7 days.

Fast forward ten years, we are living in an era reminiscent of the early 1900s, with fascist governments ruling several countries, different wars taking place in the name of peace, and a pandemic still very much omnipresent yet being ignored by many. Some have even started calling it the post-COVID era, while newer variants of the virus are still being discovered, and a fresh spike in cases in several countries has marked the arrival of another wave of remorse. Due to the COVID-19 pandemic, these last two years have seen a drastic increase in the use - and misuse - of antibiotics, and consequently, the rise of antibiotic resistance in pathogenic bacteria - which was already a global threat before the pandemic struck.

In the early days of the pandemic itself, several scientists raised their concerns about a potential rise in the cases of antibiotic resistance during the pandemic, if proper measures weren’t taken to ensure their controlled use. They also warned us about the potential triple threat of COVID-19, bacterial co-infections, and antibiotic resistance [1, 2] and suggested several steps for proper antibiotic stewardship in order to curb the spread of antibiotic resistance. [3]

Certainly, as the months progressed, case studies of outbreaks of bacterial co-infections from hospitals around the world started getting reported. A meta-analysis of 38 such reports concluded that out of the total 1959 bacterial isolates in those outbreaks, 29% were antibiotic resistant. Among these resistant organisms, the most prevalent ones were: methicillin-resistant Staphylococcus aureus, carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumanii, and Pseudomonas aeruginosa (all four belonging to the notorious hospital-associated group of ESKAPE pathogens), and multiple-drug resistant Candida auris. [4]

According to a study in the journal PLOS Medicine [5], India alone saw an excess sale of 216 million doses of antibiotics within the first peak of COVID infections in the country, that is, between June and September 2020. It was not only antimicrobials that were used more than necessarily but also biocidal agents like surface sanitizers and antiseptic agents. Several concerns regarding the effect of these biocides on antimicrobial resistance have also been flagged, since they can lead to providing resistance to the bacteria through introduction of membrane modifications and increase in the production of efflux pumps. The former of these methods stops the antimicrobial molecules from attaching with the bacteria’s surface, thereby not letting them enter the organism and cause any damage, while the latter method pumps out any harmful molecules that have found their way into its cytoplasm [6].

In his book about microorganisms around and within us, I Contain Multitudes, Ed Yong mentions that in a hospital setting, not just unhygienic conditions, rather overtly clean surfaces can also carry several pathogenic bacteria. He pins this on the dysbiosis, or disturbance in the proportion of beneficial bacteria present in any setting, caused by a high use of antibacterial sanitizers. He also goes on to cite Dr Jack Gilbert’s work [7], who had been researching the microbiomes of built environments when the book came out in 2016 (a comprehensive review of the same was published in 2018). Dr Sean Gibbons, then a student of Dr Gilbert, studied the microbiome of restroom surfaces and concluded that toilets that are scrubbed and cleaned more often tend to have more faecal bacteria on them [8]. According to them, one of the solutions to make sure pathogenic bacteria do not get a hold of patients in hospital settings is to make sure that instead of exterminating all the bacteria, a healthy diversity of the so-called good bacteria are present on hospital surfaces. For that purpose, they have been developing a sort of probiotic concoction for it. [9]

Moving forward, I hope that certain changes in the way we understand and utilize antimicrobial agents, including antibiotics, are implemented. This might include developing SOPs and policy changes for the sale and use of antibiotics, conducting outreach activities to inform the general populace about the ill effects of their misuse, and thorough monitoring of antibiotic resistant bacteria and their functioning. Better antibiotic stewardship practices need to be implemented so that one day the examples of antibiotic misuse only remain a thing of the past. Research in the direction of discovering better alternatives to antibiotics and other antimicrobial compounds may also need to be fast tracked.

Acknowledgements:
I am grateful to Preethika Nair for discussing the first draft of this article with me.

References
1. A.K. Murray, “The Novel Coronavirus COVID-19 Outbreak: Global Implications for Antimicrobial Resistance.” Front. Microbiol., 2020, 11:1020. doi: 10.3389/fmicb.2020.01020.
2. J.A. Bengoechea, & C.G. Bamford, “SARS-CoV-2, bacterial co-infections, and AMR: the deadly trio in COVID-19?” EMBO mol. med., 12(7), e12560, 2020. https://doi.org/10.15252/emmm.202012560.
3. B.D. Huttner et al. “COVID-19: don't neglect antimicrobial stewardship principles!” Clinical microbiol. and infection, 26(7), 808–810, 2020. https://doi.org/10.1016/j.cmi.2020.04.024.
4. R.M. Kariyawasam et al. “Antimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019–June 2021).” Antimicrob. Resist. Infect. Control 11(45), 2022. https://doi.org/10.1186/s13756-022-01085-z.
5. G. Sulis et al., “Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis.” PLoS Med. 18(7): e1003682, 2021. https://doi.org/10.1371/journal.pmed.1003682.
6. L.J. Bock, “Bacterial biocide resistance: a new scourge of the infectious disease world? (2019) Arch. Dis. Child. 104(11):1029-1033. doi: 10.1136/archdischild-2018-315090.
7. J.A. Gilbert, B. Stephens, “Microbiology of the built environment.” Nat. Rev. Microbiol. 16, 661–670, 2018. https://doi.org/10.1038/s41579-018-0065-5.
8. S.M. Gibbons, “Ecological succession and viability of human-associated microbiota on restroom surfaces.” Appl. and env. microbiol., 81(2), 765-773, 2015. https://doi.org/10.1128/AEM.03117-14.
9. Ed Yong, “I contain multitudes: the microbes within us and a grander view of life.” London, UK: The Bodley Head, an imprint of Vintage, 2016. Epub ISBN: 9781473520189.

The article was first published here.