Antibiotics for COVID-19: why it is useless and even dangerous
The COVID-19 pandemic provoked a massive intake of antibiotics without obvious indications - to prevent infection, "just in case" and "to clear the conscience." However, this is dangerous for the sick and for humanity as a whole: this use of antibiotics only increases the resistance of bacteria to antimicrobial drugs. At a critical moment, they may simply not work. Edition "Meduza" found out how doctors are trying to cope with the massive intake of drugs - and what consequences of an antibiotic addiction will be fought in Russia by a commission led by Dmitry Medvedev.
One of the journalists of the publication fell ill with COVID-19 at the very end of September - she realized that something was wrong when her husband lost his sense of smell and had a fever. She did not notice any symptoms in herself, except perhaps severe weakness and constant fatigue. Together with her husband, they passed the tests, both received positive results, the two of them waited for the doctor.
The local doctor prescribed treatment for them: he brought with him and gave out several packages of drugs, including the antibiotic azithromycin. “I am a doctor, when he confidently took it all out of his bag, I asked: 'Do you need to drink this?' He said: 'There is a recommendation to give it to you, and then you decide for yourself,'” the journalist recalls. So she became one of hundreds of thousands of patients who were given antibiotics without indication.
“This is a template of consciousness, do you understand? - says the doctor of the clinical hospital No. 4 of the Sechenov University, the chief pulmonologist of the Ministry of Health Sergei Avdeev. - Any doctor thinks: if COVID-19, then there may be pneumonia. Since pneumonia means a respiratory tract infection. And if there is a respiratory tract infection, then antibiotics are needed.
According to Avdeev, in Russian regions, from 50% to 80% of patients with COVID-19 are treated with antibiotics. According to a recent analysis, in hospitals at Sechenov University, about the same 70% of patients received azithromycin. Similar statistics are given by the WHO, but on a global scale: antibiotics were prescribed to 72% of patients with COVID-19.
“There is no sense in antibiotics at the initial stage of COVID-19, it's a viral disease,” Avdeev continues. - Antibiotics are needed only if a bacterial infection is added to the virus. And whether it will be difficult to predict in advance. Because of this complexity, doctors prescribe antibiotics just in case. They have a familiar scenario in their heads: there was the flu, with it, the addition of a bacterial infection happens often. But coronavirus infection is not the flu. "
Despite the similarities - viral pneumonia and respiratory failure, with COVID-19, unlike influenza, bacterial infections develop only in 7-8% of hospitalized patients. For this reason, WHO does not recommend the use of antibiotics for mild COVID-19, and for moderate COVID-XNUMX, they should be prescribed only if there are symptoms of a bacterial infection.
Avdeev is sure: the more antibiotics, the more bacteria resistant to them. This means that the more deadly superinfections caused by them are in the intensive care units of hospitals - when, without recovering from one infection, a person becomes infected with another.
Death in intensive care
Doctors in Russia are already writing appeals to colleagues urging them to stop using unnecessary antibiotics.
Head of the Department of General and Clinical Pharmacology of the Peoples' Friendship University of Russia, Deputy Chief Physician of Moscow Hospital No. 24 Sergei Zyryanov recalls a patient who died in intensive care from superinfection. “She was about seventy - first severe COVID-19, then this. She could not stand the double intoxication. After taking antibiotics, elderly patients often develop pseudomembranous colitis - we have always dealt with this before, but we could not do anything about it.
Zyryanov himself was sick with COVID-19 in March - hard, five weeks. When asked what he was treated with, Zyryanov honestly answers: he drank the antibiotic amoxicillin. "Why? First, I didn't want to believe the worst; secondly, then little understood anything about COVID-19. If I got sick now, I would have been treated differently and at the initial stage I would not have prescribed any antibiotics for myself, ”the doctor explains.
During the first wave, almost three thousand patients were treated for COVID-19 at the Zyryanov hospital. Mortality is standard for Moscow 10-15%.
The main cause of mortality in coronavirus in his clinic was first named by doctor Denis Protsenko: in 73% of cases these were superinfections. “We have carefully analyzed the causes of mortality. It was mainly community-acquired pneumonia, overwhelmingly caused by COVID-19. 73% of deaths were recorded later in hospitalization [after 72 hours], and the majority were caused by superinfection, which led to sepsis, ”Protsenko said. According to him, in just three months, the number of antibiotic-resistant bacteria in hospital intensive care units has increased several times.
Several employees of Moscow hospitals told on condition of anonymity that up to 50% of patients in intensive care die from the consequences of superinfections.
If a bacterium appears in the intensive care unit, it is very difficult to prevent its full spread - “it doesn’t sparkle or glow,” explains Daria Kamyshova, clinical pharmacologist at the Pirogov Center. “No matter how hard the medical staff tries to ensure thorough infection control and transfer patients to separate boxes, it can still happen that the same strain will appear in another place, - roughly speaking, the infection can be transferred from bed to bed if an emergency happened at the doctor there is no way to quickly change a disposable gown or properly treat your hands. This problem cannot be avoided, it was always in intensive care - before the pandemic, during the pandemic. " However, in patients with damaged COVID-19 lungs, and even taking several types of antibiotics, the risk of infection is much higher than in other people in intensive care, Kamyshova said.
“If five years ago in my arsenal there were five to seven antibiotics with which I could treat the nosocomial microflora, then before the epidemic I already had one or two such antibiotics. And now I have to invent combinations of antibacterial drugs that will allow me to solve the problems of antibacterial therapy in severe patients, ”complained Sergei Tsarenko, deputy chief physician for anesthesiology and resuscitation at Moscow Hospital No. 52.
To cure a patient of superinfections, doctors in intensive care units are now making cocktails (combinations of several drugs) in the hope that it will work. “Before, when you prescribed two types of antibiotics at the same time, you were looked at as a pest. And now we have to prescribe three and four to patients in intensive care, ”says Zyryanov. The drugs, he explains, are prescribed in excess of the doses indicated in the instructions and their level in the blood serum is monitored in order to quickly change the composition if necessary.
In ordinary cases, you can come up with a combination of antibiotics and cure the patient, but when all the combinations have already been tried, there is practically nothing to treat, Kamyshova says. And if, during the treatment of a person from COVID-19 and its consequences, doctors have already had to change several types of antibiotics, the patient's chances of dying on a ventilator are growing, explains Skoltech professor, microbiologist Konstantin Severinov.
"I gave the medicine - I disclaimed responsibility"
The journalists talked to two dozen patients with mild and moderate forms of COVID-19 - they were treated at home, they were prescribed medications in private and public clinics. They were not tested for bacterial infection before the appointment. Patients were prescribed antibiotics amoxicillin, levofloxacin, and if it did not help, ceftriaxone was added. Alternatively, azithromycin (often in combination with the antimalarial hydroxychloroquine).
“What I saw in the anamnesis of our patients: about 90% of those who went to the doctors at the outpatient stage, received, relatively speaking, a la antiviral drugs for three days, then one antibiotic came - it does not help, after three days the second - does not help, then the third, and so on. Patients were admitted to the hospital after drinking three types of antibiotics in a week. You can go crazy! " - recalls Kamyshova.
“For example, I myself did not prescribe antibiotics to mild patients, but my colleagues did so. Gave the patient medicine - disclaimed responsibility. What if he has a bacterial infection, in addition to everything, appears in a day? There will not be a doctor who has a hundred COVID-19 patients on the site to check each one daily. And whether the antibiotic will help or not - well, we'll wait and see, ”says a local therapist of one of the Moscow polyclinics.
A similar therapy is used in the hospitals themselves. “They gave me paracetamol only because of the temperature, but it didn't help. I was very angry that they were doing nothing except paracetamol. Treatment of patients is sluggish - until a decision is made, you can already drop your skates. But in the end it all ended well for me. I myself and my family cut off the hotline of this hospital, and they began to give medicine, ”one of the patients of the hospital No. 15 wrote to them. Filatov - one of the largest hospitals in Moscow, where patients with COVID-19 are treated. Among the drugs that the patient knocked out with a fight, the antibiotics amoxicillin and levofloxacin.
“We have clearly defined the parameters for prescribing antibiotics for COVID-19 - only with leukocytosis, high levels of procalcitonin and purulent sputum. If this is not all, such drugs are not needed, but they continue to be prescribed en masse, ”Avdeev says about the recommendations of the Ministry of Health for the treatment of coronavirus infection.
“We are prescribed antibiotics if an X-ray is taken and pneumonia is visible. If there is viral pneumonia, it means that the lung tissue is already damaged and there will certainly be a bacterial complication, - argues with Avdeev a doctor at one of the infectious diseases hospitals in Saratov. - If there is no pneumonia, antibiotics are not needed. If you have pneumonia, you need it. " At the same time, she considers it justified to prescribe these drugs at the outpatient stage, "as a prophylaxis against infections" (WHO does not recommend the use of antibiotics as a prophylaxis). The Saratov infectious disease specialist is sure: if the patient nevertheless ends up in intensive care and encounters a serious infection, he will in any case be treated with other drugs - reserve antibiotics.
At some point, due to the massive intake of antibiotics, the reserve drugs will simply stop working, and we will lose the last line of defense, says Ksenia Ershova, a doctor in the Department of Anesthesiology and Intensive Care at Washington State University Hospital in Seattle. Ershova has been studying the problem of infection resistance to antibiotics for several years.
“Over time, many pathogenic bacteria have developed resistance not even to one, but to all types of antibiotics that are in the arsenal of doctors. Since there was nothing to treat the sick, they began to die more often. Due to the COVID-19 pandemic, the situation is seriously worsening: the use of antibiotics has increased, which means that resistance to them has also increased. In short, everything is bad, ”says microbiologist Konstantin Severinov.
National security issue
In a pandemic, it is very difficult to deal with excessive intake of antibiotics, admits the deputy chief physician of hospital No. 24 Sergei Zyryanov: “I myself ask the patient during the round:“ What did you drink from antibiotics in the last 90 days? ”In theory, if we reduce the use of antibiotics, resistance to them will decrease ... But we don't have time for that now. "
According to the estimates of the marketing company DSM Group, from January to August 2020, 90 million packages of antibiotics were purchased from Russian hospitals and pharmacies for a total of over 13 billion rubles. The regions are already massively complaining about their lack.
At the same time, "many pharmacy organizations, in pursuit of profit, are selling prescription drugs without such", admits the Minister of Health Mikhail Murashko in an interview with RIA Novosti about antibiotics. At the beginning of October, Roszdravnadzor finally approved the regulation for checking drug sales in pharmacies, including a "test purchase" - the minister hoped for this measure.
The authorities are trying to tackle the problem of growing antibiotic resistance with varying success and at different levels. In the government bill "On the biological safety of the Russian Federation", the spread of drug resistance is included in the list of the main biological threats. The document, in particular, should reduce the availability of antibiotics and put under strict control their production, circulation and use - for example, prohibit the prescription of such drugs without a confirmed diagnosis and use them when there is no positive dynamics of treatment.
At the first hearing of the bill in the State Duma on January 21, 2020, the deputies spoke not only the usual words about threats from the West, where "work on biological weapons continues," but also about the new Chinese virus - a clear "threat to Russia's biological security." The second hearing was scheduled for March, but it has not yet passed.
In October, the Security Council got involved in this topic - President Vladimir Putin signed a decree on an interdepartmental Security Council commission on the creation of a national system of protection against new infections. It will include the heads of the Ministry of Industry and Trade, the Federal Medical and Biological Agency, the Ministry of Health, the Kurchatov Institute, as well as the deputy head of the FSO and the FSB. Chaired by the Deputy Chairman of the Security Council Dmitry Medvedev, the commission will “assess internal and external threats” associated with antibiotic-resistant microbes. The commission has not yet begun work, said a source familiar with the details of the project. And he does not expect a quick solution to the problem: "They will think for a long time, but it is already necessary to treat people with something."
To some extent, Moscow clinics can be helped by the latest mass spectrometer, which was installed in the N.N. Sklifosovsky. They promise that this device is able to determine the microorganism that caused the infection in just 20-30 minutes, and to establish how resistant the pathogen is to antibiotics - in seven hours. This will allow the doctor to choose an effective drug therapy regimen, said the head doctor of the hospital Sergei Petrikov.
The Moscow health department has not yet answered whether they will purchase such mass spectrometers for other hospitals. There were also unanswered questions about the volume of analyzes already carried out with the help of the latest mass spectrometer - and whether the capacity of one device is enough for overloaded clinics.
Infections caused by antibiotic-resistant bacteria cannot be compared to plague or cholera. But if the body is already weakened by something else (be it AIDS or complications associated with mechanical ventilation), such infections can lead to serious trouble. “If there are antibiotics that can treat it, that's one thing,” says microbiologist Severinov. "If they don't work - death."
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