During the early phase of the Covid-19 pandemic, there was widespread uncertainty surrounding its potential to claim lives. As there wasn’t any curative treatment for Covid-19, it is crucial to question how the patients were treated and how the uncertainty exerted pressure on using medications without evidence. A recent PLoS Global Public Health study titled “Use of antimicrobials during the Covid-19 pandemic: A qualitative study among stakeholders in Nepal” explored whether and how antimicrobials (antibiotics) were used during the pandemic, and some prominent findings offer us insights to act cautiously for the next pandemic.

Antimicrobials are drugs called “antibiotics” that are active against germs, including bacteria, parasites and fungus. The special antimicrobials against viruses are called antivirals and are rarely prescribed unless there is clear evidence of viral infections. In Nepal, antimicrobials or antibiotics are almost unrestricted, as these medications can be easily bought over the counter (OTC) from numerous pharmacies or drug shops. Aligning with the policy, antimicrobials are recommended to be used judiciously based on establishing infections by microbes.

Unfortunately, their purchase can be as simple as buying commodities in a grocery shop. However, easy access to antimicrobials cannot be attributed as a sole problem to the rampant use of antimicrobials, particularly as these drug outlets serve as informal health services’ structural units, even if their services can be sub-optimal. With the widespread and empirical use of antimicrobials, OTC is often considered to accentuate the rising threat of antimicrobial resistance (AMR). AMR is likely to contribute to untreatable infections in the future. An example can be an unhealing razor-cut injury during shaving, leading to life-threatening conditions. AMR is a significant public health threat likely to incur a substantial economic burden, requiring us to reflect on how Covid-19 may have pressured antimicrobial use and the development of AMR.

First, the uncertainty in the curative measures for Covid-19 in its early phases offered a vulnerable background to the at-risk population. It thus resorted to diverse empirical treatments, including experimentation with unproven medications, advice and measures. The pandemic offered an example of uncertainty, giving rise to the proliferation of unsubstantiated measures, including suggestions from the then United States President Donald Trump on the use of hydroxychloroquine, Nepal’s former prime minister KP Sharma Oli on the use of herbs, and several other heads of state and celebrities who added their opinions for the cure of Covid-19.

Second, many patients who developed the symptoms of Covid-19 were fraught with fear and discrimination from their family members, neighbours and wider circle. As a result, those who showed symptoms suppressed their illness by taking OTC antimicrobials from nearby drug shops; some of these drug outlets sold cocktails of antimicrobials claiming to cure Covid-19. People feared getting tested because of the risk of a positive case, and thus hiding the conditions until they became severe was a major defense mechanism they adopted. In the worst cases, most patients had to be admitted to wards and intensive care units (ICUs). However, the ICUs and hospital wards struggled to offer beds and spaces to the patients, overwhelming the healthcare workers.

Third, healthcare workers suffered major burdens due to an unprecedented number of patients needing acute care and uncertainty around the effectiveness of treatment. As a result, most clinicians had to resort to whatever was available, including the use of antimicrobials. While Covid-19 resembled respiratory symptoms, a proportion of these patients also had bacterial co-infections, and empirical treatment (including prophylactic treatment) to prevent potential co-infections became the norm. The compounding effect of patients’ burden, uncertainty of treatment and rationale to prevent co-infections led to the use of antimicrobials.

Fourth, an essential background to the current surge in antimicrobial usage is its prior use, mostly from drug outlets, intensified by the pandemic. While the OTC use of antimicrobials is deemed to enhance AMR’s burden, their use alone cannot be curtailed by policy guidelines because alternative sources of health care, including diagnostic-based treatments, are largely missing. In low- and middle-income countries, empirical treatments are often the mainstay of infection management at formal and informal health service centres. While we discuss the implications of OTC and the empirical use of antimicrobials, the baseline understanding of antibiotics by the population is essential. After all, people-centred approaches are crucial for the success of any intervention. In the PLoS Global Public Health study, we found only a few patients aware of the antimicrobials, let alone the knowledge about the consequences of their over-use.

Finally, there are policy implications that can be strengthened in terms of both the OTC use of antimicrobials and prescription-based empirical treatment. Nonetheless, stringent policies to clamp down on antimicrobials without preparation could have huge ramifications, jeopardising access to easily available health services at informal levels. Pragmatic steps can be crucial at the population level to increase awareness of what antimicrobials are and how their use needs careful consideration by all stakeholders, for example, in the use of antimicrobials in animal health and agricultural sectors, which is largely neglected. These factors are equal or more prominent contributors to the current threat of a rise in AMR. While structural reforms in health care sectors, including policy strengthening are crucial in the long run, the foremost steps are to expedite community engagement and campaigns, including mainstream media’s involvement to sensitise the population about antimicrobials and their consequences due to over-use.