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.