Introduction
Coronavirus disease 2019 (COVID-19) is caused by the new coronavirus
known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
which first appeared in Wuhan, China in December 2019 (WHO, 2020). In
Lebanon, the first case of coronavirus was confirmed on February 21,
2020. From that point forward, Lebanon has had over 400,000 cases with
worldwide cases reaching over 120 million confirmed cases across 221
countries and territories and over 2 million deaths. This disease is
characterized by typical symptoms including fever, dry cough and fatigue
and other less common symptoms such as losing smell or taste, muscle
pain, nasal congestion and nausea or vomiting (WHO, 2020). Around 80%
of COVID-19 infected patients do not require hospitalization, 15% can
become severely ill and only 5% become critically ill requiring
hospitalization (WHO, 2020). Among those patients, there is an increase
in the prescribing of antibiotics due to the concern of bacterial
superinfection and hence an increase in antimicrobial resistance (AMR)
(Beović et al., 2020).
COVID-19 has shifted the focus of healthcare and created further
challenges to the health and social care systems with huge strains being
placed on global resources (Rawson et al., 2020b). It is predicted that
the redundant use of antibiotics might increase as an indirect outcome
of this pandemic. This unnecessary use can cause allergic reactions,
adverse events related to antibiotics and an increase in AMR (Seaton et
al., 2020). AMR is perceived as a real global challenge threatening
human and animal health. Several associations, international agencies,
and governments have emphasized the urgency of this problem
(Rodríguez-Álvarez et al., 2020). The pattern of AMR will unquestionably
change with the emergence of COVID-19 pandemic. Therefore, it is
critical to consider and evaluate the outcomes of this pandemic on the
use of antibiotics and AMR (Rawson et al., 2020a). In addition, it is
essential to develop antimicrobial policies and guidelines that will
limit the unnecessary prescription of antibiotics and maintain constant
observation of AMR rates (Rawson et al., 2020a).
According to the World Health Organization (WHO), antibiotics should not
be used to prevent or treat COVID-19 (WHO, 2020), however, antibiotics
are used to manage suspected or confirmed bacterial or fungal
respiratory co-infections in patients with COVID-19 (Rawson et al.,
2020b). Studies considered that bacterial co-infection is a risk factor
for the mortality rate in patients with COVID-19 (Liu et al., 2020).
Therefore, during this pandemic, it is expected that more patients will
receive empirical antibiotic therapy (Rawson et al., 2020b) however,
most patients receive the therapy before even being diagnosed with
bacterial infection (Liu et al., 2020). Moreover, recent studies showed
that the rate of bacterial co-infection in COVID-19 patients is low.
Despite this, overprescribing of antibiotics is evident and use of
broad-spectrum antibiotics is high
(Rawson et al., 2020a). For this reason, healthcare systems must manage
the optimal selection of empirical therapy. This should be followed by
the de-escalation of antibiotics when appropriate by enforcing
antibiotic stewardship programs (ASPs) and providing training to
healthcare workers on the subject (Rawson et al., 2020b). Furthermore,
according to the WHO, it is recommended that empirical antibiotic
therapy against the pathogens that cause severe acute respiratory
infection in patients with suspected COVID-19, be implemented according
to the local guidelines (Seaton et al., 2020). However, the basis for
the empirical prescription of antibiotics in suspected COVID-19 patients
is not well identified (Seaton et al., 2020).
As the pandemic progresses, it is critical that policies and guidelines
be implemented to evaluate antimicrobial use in COVID-19 patients and
hence mitigate the unintended consequences of the redundant use of
antibiotics and its impact on AMR (Rawson et al., 2020b; Stevens et al.,
2021). Moreover, healthcare systems must ensure that healthcare workers
receive training and education about antibiotic prescription and ASPs
for the management and the optimal use of antibiotics, and avoiding
unnecessary therapy that will contribute to the issue of AMR (Rawson et
al., 2020b). Physicians are responsible for diagnosing the disease,
treating, and caring for the patients. They are also prescribers of
antibiotics and are well educated in this field. However, this education
must extend to other health care workers including nurses, the first
healthcare workers to come into contact with COVID-19 infected patients,
and pharmacists who assist in managing this public health issue by
acting as a source of vital information to patients about COVID-19
(Bukhari et al., 2020). The combined efforts of healthcare workers and
their participation is vital to end this outbreak. Therefore, focus on
providing suffienct knowledge to physicians, nurses, and pharamcists
regarding antibiotic use is essential especially during the period of
COVID-19 in order to diminish the collateral consequences of this
pandemic on the issue of AMR. However, there is limited data regarding
knowledge and attitudes of healthcare workers regarding antibiotic use
in COVID-19 patients. Not much research has been carried out in this
domain and till now no such study has been conducted in Lebanon.
Therefore, the purpose of this study is to assess the perception of
healthcare workers regarding antibiotic use during COVID-19 pandemic in
Lebanon.