COVID-19 & Antimicrobial Resistance

The U.S. lost progress combating antimicrobial resistance in 2020 due, in large part, to effects of the COVID-19 pandemic. The CDC COVID-19: U.S. Impact on Antimicrobial Resistance, Special Report 2022 [PDF – 44 pages], concluded that the threat of antimicrobial-resistant infections is not only still present but has gotten worse.

During the first year of the pandemic, more than 29,400 people died from antimicrobial-resistant infections commonly associated with healthcare. Of these, nearly 40% of the people got the infection while they were in the hospital.

The total national burden of deaths from antimicrobial resistance may be much higher, but data gaps caused by the pandemic hinder that analysis. CDC is missing data for nine of the 18 pathogens listed in its 2019 AR Threats Report. CDC’s 2019 estimates are still the strongest data to show the U.S. burden of antimicrobial resistance—at least 2.8 million antimicrobial-resistant infections continue to occur in the U.S. each year and more than 35,000 people die as a result.

In the 2019 AR Threats Report, CDC reported that nationwide investments in prevention drove down deaths from antimicrobial-resistant infections by 18% from 2012 through 2017. CDC data show these reductions continued until 2020. But the pandemic resulted in more resistant infections, increased antibiotic use, and less data and prevention actions.

This setback can and must be temporary. If properly resourced, the U.S. can continue to build resilient public health and healthcare systems to keep our nation safe from antimicrobial resistance.

COVID-19 Impact on Healthcare Facilities & Community Settings

U.S. healthcare facilities saw more healthcare-associated, antimicrobial-resistant infections, especially in hospitals. Hospitals treated sicker patients who required more frequent and longer use of medical devices like catheters and ventilators. Hospitals also experienced personal protective equipment supply challenges, staffing shortages, and longer patient visits.

• Resistant hospital-onset infections and deaths both increased at least 15% from 2019 to 2020 among seven pathogens.
• A 2021 CDC analysis reported that, after years of steady reductions in healthcare-associated infections (HAIs), U.S. hospitals saw significantly higher rates for four out of six types of HAIs in 2020. Many of these HAIs are resistant to antibiotics. 
• Antifungal-resistant threats rose in 2020, too, including Candida auris—which increased 60% overall—and Candida species (excluding Candida auris), with a 26% increase in infections in hospitals.

In communities, CDC has limited data for the spread of antimicrobial-resistant pathogens, like drug-resistant gonorrhea and foodborne germs.

• Public health personnel nationwide were diverted to the pandemic response and people (potential patients) had reduced access to care and testing services.
• Many clinics and healthcare facilities limited services, served fewer patients, or closed their doors entirely in the face of challenges from COVID-19.
• Before the pandemic, CDC data showed many resistant infections often found in the community were increasing (2012-2017). CDC is concerned that resistant infections continued to spread in communities undetected and untreated in 2020.

COVID-19 Impact on Five Core Actions to Combat Resistance

CDC targets five core actions to better prepare the U.S. to combat antimicrobial resistance, integrating a One Health approach to comprehensively tackle new threats that will continue to emerge worldwide. The pandemic impacted these core actions.

• Tracking and Data
• Preventing Infections
• Antibiotic/Antifungal Use
• Environment and Sanitation
• Vaccines, Therapeutics, and Diagnostics

Tracking and Data: COVID-19 Impact

• Tracking antimicrobial resistance, including detection and reporting data, slowed tremendously during the COVID-19 pandemic because of changes in patient care, testing, treatment, and the staff availability of healthcare facilities and health departments.
• Knowing where and how changes in resistance are occurring informs solutions (e.g., outbreak response) to prevent spread and slow resistance.
• CDC’s AR Lab Network received and tested 23% fewer specimens or isolates in 2020 than in 2019. It continued to collect isolates throughout 2020 using established processes, but some isolates remain untested due to testing backlogs. This may be because healthcare facility and public health staff had to shift focus to COVID-19.

Preventing Infections: COVID-19 Impact

• It is vital to prevent infections before they start, including in our communities and when in a healthcare facility.
• Unfortunately, pandemic-related challenges weakened many infection prevention and control practices in U.S. healthcare facilities, undoing some progress on combating antimicrobial resistance. Infection prevention and control practices includes hand hygiene, cleaning equipment, separating patients, and appropriately using personal protective equipment.
• There were more and sicker patients during the pandemic who required more frequent and longer use of catheters and ventilators. This may have increased risk of HAIs and spread of pathogens, especially when combined with personal protective equipment and lab supply challenges, reduced staff, and longer lengths of stay.

Antibiotic/Antifungal Use: COVID-19 Impact

• Antibiotic use throughout the pandemic varied across healthcare settings. Antibiotics were commonly prescribed to patients with COVID-19, even though antibiotics are not effective against viruses like the one that causes COVID-19.
• Almost 80% of patients hospitalized with COVID-19 received an antibiotic from March to October 2020. Antibiotics and antifungals can save lives, but any time they are used—for people, animals, or plants—they can contribute to resistance.
• In hospitals, approximately half of hospitalized patients received ceftriaxone, which was commonly prescribed with azithromycin. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital for assessment.
• In outpatient settings, antibiotic use significantly dropped in 2020 compared to 2019 due to less use of outpatient health care and less spread of other respiratory illnesses that often lead to antibiotic prescribing. Outpatient antibiotic use rebounded in 2021 but was still lower overall in 2021 compared with 2019. From 2020 through December 2021, most antibiotic prescriptions for adults were for azithromycin and increases in azithromycin prescribing corresponded to peaks in cases of COVID-19.
• In nursing homes, antibiotic use spiked alongside surges of COVID-19 cases but remains lower overall. However, azithromycin use was 150% higher in April 2020 and 82% higher in December 2020 than the same months in 2019. Azithromycin prescribing remained elevated through October 2020. In 2021, antibiotic use overall was, on average, 5% lower than 2019. This decrease might be due to fewer nursing home residents during this time.

Environment and Sanitation: COVID-19 Impact

• Researchers leveraged an existing CDC AR Solutions Initiative funded-project to better understand the burden of COVID-19 in communities using wastewater (sewage).
• In September 2020, CDC established the National Wastewater Surveillance System (NWSS) to provide community-level data on COVID-19 infection trends by looking for markers in wastewater that tell scientists when SARS-CoV-2 is present.
• Antimicrobial resistance is a One Health issue, impacting the health of humans, animals, plants, and the environment. Efforts to identify antimicrobial-resistant germs, track the spread of resistance, and measure the effect of antibiotic and antifungal use require surveillance across human, animal, and plant populations and the environment.

Vaccines, Therapeutics, and Diagnostics: COVID-19 Impact

• The COVID-19 pandemic highlighted the need to stop the spread of germs before they can cause an infection.
• Treatment after infection occurs is not the only solution and should not be the only option. The U.S. needs more prevention products, not just new drugs, to stop infections before they happen.
• These include alternatives to new antibiotic and antifungal drugs, new vaccines to combat infections that can develop antimicrobial resistance, and novel decolonizing agents to stop the spread of antimicrobial-resistant germs by people who may not know they are carriers.

Fact Sheets, Graphics, & Videos

Share these fact sheets and social graphics about how the COVID-19 pandemic has impacted five core actions to combat antimicrobial resistance.

More Information

• COVID-19 Impact on HAIs
• Invasive Candidiasis in Patients with COVID-19
• Increased Spread of C. auris During COVID-19 Pandemic
• COVID-19-Associated Pulmonary Aspergillosis
• CDC Presentations at the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria: Feb. 2021 slides [PDF – 35 pages] and Sept. 2020 recording and slides [PDF – 24 pages]
• 2020 STD Prevention Conference Panel Discussion (recording and transcript) and a National Coalition of STD Directors survey