During the last year and a half, the world’s attention has been focused squarely on SARS-CoV-2, the coronavirus that causes COVID-19. While deadly, this virus is only one of many pathogens that threaten our well-being. For many years, scientists have been warning about another microscopic menace: drug-resistant microbes.
Antimicrobial resistance, or AMR, poses a serious threat to health systems and economies around the globe. Unlike COVID, however, AMR is a slow-moving disaster—the worst effects will not be seen for years to come. “Unless we deal with this issue, by 2050, we’re going to have a big problem,” says Dr. Paul Thomassin, BSc(Agr)’78, a professor of Agricultural Economics and former director of the McGill Centre for the Convergence of Health and Economics. “Not only in terms of the number of people who die, which is obviously a major social concern, but also in terms of the economic impact.”
The pandemic itself may have also shifted the course of AMR. Before COVID emerged, there was growing momentum globally to address so-called “superbugs,” bacteria and other microbes that are impervious to most of the medications available to fight them. However, when clinicians, researchers and policymakers pivoted to dealing with the crisis at hand, AMR took a back seat.
On top of that, specific practices and challenges related to COVID, such as an uptick in antibiotic prescriptions, may have worsened the AMR problem. “Most leaders in antimicrobial resistance are extremely concerned that we either have stalled, or perhaps even lost, some of the gains made in recent years,” says Dao Nguyen, MDCM’97, PGME’02, MSc’04, an associate professor of Medicine at McGill, an investigator at the Research Institute of the McGill University Health Centre, and director of the new McGill Antimicrobial Resistance (AMR) Centre. (Dr. Nguyen is pictured above, left).
As the COVID pandemic wanes—at least in some parts of the world—scientists are beginning to turn their attention back to AMR. At McGill, researchers across many different fields, from medicine to economics, are banding together to take an interdisciplinary approach to prevent superbugs from becoming another global health crisis.
While the full extent remains to be seen, AMR experts suspect certain changes that occurred during COVID may have had significant effects on the battle against superbugs.
One potential issue stems from the increase in antibiotic use that happened in the early days of the pandemic. Medical practitioners faced with patients suffering from an infectious illness of unknown cause turned to antibiotics. “Antibiotic use went up in the hospital setting for a period of time around the world, and it probably went sky high in some places where testing for COVID is not very available,” says infectious disease expert Dr. Makeda Semret, BSc’88, PGME’01 (pictured above, right), who is an associate professor in the Department of Medicine at McGill University and lead of the Antimicrobial Stewardship Program at the McGill University Health Centre. “We don’t have good data yet on what happened with antibiotic consumption worldwide, but if we consumed more antibiotics in the last year, we probably have worsened the crisis to some extent.”
According to Dr. Nguyen, in places like Canada, where the awareness of antibiotic stewardship is high, the use of antibiotics later subsided, but in some populations antibiotic use remained elevated for a long time. This has been partly fueled by the risk that COVID patients themselves had of developing a bacterial superinfection. “Having COVID and being in the hospital puts you at higher risk,” Nguyen explains. “In many places, there was a higher rate of hospital-acquired infection—and some hospitals saw a greater number of outbreaks of drug-resistant bacterial infection.”
In addition, due to the stress that COVID put on medical systems' resources that had previously been devoting to dealing with AMR were shifted to dealing with the more urgent issue of the coronavirus. “Different departments—for example, people who are doing surveillance on antimicrobial resistance—were pulled off what they usually did,” Thomassin says. “So there could be gaps in the data in terms of exactly how antibiotics were being distributed, and also what was happening in terms of the surveillance for antimicrobial resistance.”
Such pivots also occurred outside of the clinical realm as well. “There definitely have been delays in research projects and legislative projects that were focused on AMR,” Nguyen says. “Those have been put on the back burner until people are back on track or available to address AMR.”
On the flip side, the pandemic has also had some potential positive effects in the fight against AMR. For example, the development of better testing kits have helped improve the diagnosis of infectious diseases. “More and more hospitals and medical systems are starting to think about first determining whether or not someone has a bacterial infection or viral infection before starting to prescribe antibiotics,” Thomassin says.
Beating the bugs
In some ways, AMR is like climate change: a slow-moving threat that poses a grave danger to humanity. Like climate change, there is no “magic bullet” solution for AMR. Instead, multiple interventions at many levels—from basic research aimed at discovering new antibiotics to new policies to reduce antibiotic use in both health care and industry—will be required to curb the impending crisis. “There is a long list of things to do,” Nguyen says. “We need to go outside of the old ways and widen the perspective, because it’s not a problem that can be solved just by looking at one area.”
To address this challenge, McGill is creating the AMR Centre. The Centre, whose formation is being led by Nguyen and supported by the McGill Interdisciplinary Initiative in Infection and Immunity (MI4), aims to bring together researchers from faculties across McGill—including Medicine and Health Sciences, Agricultural and Environmental Sciences, and Engineering—to address AMR. There are currently at least 50 different faculty members involved in AMR research, according to Nguyen. “The goal of the Centre is to create a community so that people can better collaborate, work in an interdisciplinary manner and have a bigger impact,” she adds.
This type of interdisciplinary approach helps address the fact that AMR comes from multiple sources. Excess antibiotic use in the medical realm is one key issue, but the use of these drugs in agriculture, and, subsequently, the food supply chain, must also be addressed, says Thomassin, whose current work is focused on the economics of antibiotic withdrawal—and how to do it responsibly.
Unlike in medicine, where antibiotics are used solely to treat infection, in agriculture, they are also used much more broadly to improve production. “If you look at some countries like Canada, approximately 60 to 70% of our antibiotic use is in agriculture,” Thomassin says. However, changing such practices will come at a cost, so it's important to know exactly how much AMR is coming from the food production system, he adds. “There are a variety of different places where you can make interventions.”
Broadly speaking, however, the “solutions are the same in agriculture and in medicine,” says Dr. Jennifer Ronholm, an assistant professor in McGill’s Faculty of Agricultural and Environmental Sciences. “We need to rethink our use: in medicine, people can’t use antibiotics for infections they don’t need them for, and us agricultural people should probably be trying to refrain from using antibiotics unless we really have to—if agriculture could get rid of the growth promotion and the prophylaxis, that would be a big step towards limiting them.”
One of the ways to solve this issue will be to find novel ways of dealing with pathogens. Ronholm, for example, is working on modifying the body’s resident microbes, which are collectively known as the microbiome, to prevent infection. Her team is currently investigating the differences in the microbiome of healthy and sick cows to identify probiotics that help ward off infection.
Others, like Semret, are dealing with the antibiotic issue from a more behavioural perspective. “My research is really on stewardship, meaning governing and improving the practices of prescribing antibiotics in the hospital setting,” Semret explains. “I’ve been doing research here and in developing countries, notably Ethiopia, which is where I’m from.” This dual approach is key, she adds, because it helps identify both the commonalities and differences across these settings—and helps identify problems in areas such as infrastructure or training to implement quality practices across the globe.
“I’m very enthusiastic about the McGill community, in general, and particularly this AMR group that’s organizing under the MI4 initiative,” Semret says. “It’s very exciting—and I think it will surprise us all.”