To the Editor—Since the report of the first cases of coronavirus disease 2019 (COVID-19), attempts have been undertaken to contain its expansion; however, to date there have been >60 million infections and ∼1.5 million people have died. This pandemic has challenged all knowledge about public health in countries and institutions around the world, and in addition to the morbidity and mortality of the disease, other conditions have appeared that threaten public health. ^{Reference Arteaga-Livias and Rodriguez-Morales1}

One of these situations that has not received adequate attention is the increase in bacterial resistance and the emergence of multidrug-resistant (MDR) strains, probably associated with multiple factors such as the collapse of health systems, self-medication of the population, indiscriminate use of antibiotics in hospitals, a false sense of security, and incorrect use of personal protective equipment (PPE). ^{Reference Donà, Di Chiara and Sharland2}

We reported an outbreak of Klebsiella pneumoniae New Delhi metallo-β-lactamase (NDM) in a Peruvian hospital where no cases of strains with this resistance had been identified previously. All patients were admitted for a diagnosis of COVID-19 and were placed in isolation and management areas for treatment. Table 1 shows the clinical characteristics of the patients included in the study.

Table 1. Clinical Characteristics of Patients With Positive Culture for Multidrug-Resistant Klebsiella pneumoniae

Klebsiella pneumoniae MDR has become a threat to public health; by itself, it has virulence factors related to high mortality as well as low response to treatment. ^{Reference Li, Zhu and Kang3} Klebsiella pneumoniae MDR was described for some time in Latin America and specifically in Peru in 2016, where an increased proportion of Enterobacteriaceae cases were carrying the NDM gene (67.5%) compared to Klebsiella pneumoniae carbapenemase (KPC)–producing bacteria (31.3%) and active-on-imipenem (IMP)–type NDM bacteria (1.2%). ^{Reference Pons, Marí-Almirall and Ymaña4} Sacsaquispe et al ^{Reference Sacsaquispe-Contreras and Bailón-Calderón5} determined that the main mechanism of resistance to carbapenems is the expression of blaNDM carbapenemase.

The COVID-19 pandemic has been superimposed on another pandemic, that of MDR bacteria. In our case, our hospital capacity was overwhelmed by patient overcrowding, so we managed patients with moderate and severe disease in patient reception areas and outpatient clinics in addition to opening a provisional intensive care unit (ICU) for critical patients. Under normal conditions, ICUs are the epicenters for the development of MDR bacteria.6

Another mechanism facilitating MDR spread is the irrational use of antibiotics, which were given due to the initial suspicion of superimposed infections. International reports indicate that up to 70% of hospitalized COVID-19 patients receive antibiotics, and these are often broad-spectrum agents, despite results that indicate a low proportion of bacterial infections. ^{Reference Monnet and Harbarth7} For this reason, treatment guidelines do not recommend the use of antibiotics in patients with mild or moderate disease unless the suspicion of bacterial confection is important. ^{Reference Getahun, Smith and Trivedi8}

Cross contamination via the hands of the staff would be the main means of transmission; unfortunately, no further audit was possible due to the work overload in all areas of our hospital. Furthermore, the overload of the health systems and staff burnout may have decreased adherence to infection prevention and control, which may have facilitated the spread of MDR germs. ^{Reference Bogossian, Taccone and Izzi9}

The limited and inappropriate use of PPE is another factor to consider. ^{Reference Donà, Di Chiara and Sharland2} Due to the great demand for this equipment, we experienced deficiencies in its availability and have had only 1 set of PPE to be used with all patients and throughout the shift, which could have facilitated the spread of germs from staff to the patients.

The hospital overflow and the isolation of health personnel with risk factors had to be mitigated by hiring young personnel who were poorly trained in the management of infections associated with health care. Suggestions for controlling the spread of bacterial resistance in the context of the COVID-19 pandemic include increasing the competencies of physicians in the proper treatment of SARS-CoV-2, correct recognition of symptoms of superimposed infections, eliminating the unnecessary use of antibiotics, and assessing the need for the use of devices that are known to increase the probability of infection. ^{Reference Bogossian, Taccone and Izzi9}

In addition, when treating a patient presenting with severe pneumonia due to COVID-19, in a state of immunological depression and in need of mechanical ventilation, it is necessary to consider the possibility of coinfection, as occurred with 2 of our patients. Thus, it is important to search for other bacteria with equal or greater virulence because coinfections may exist in hospitalized patients with COVID-19. ^{Reference Porretta, Baggiani and Arzilli10}

In conclusion, while we find ourselves in a pandemic state due to a virus that is not yet fully understood, COVID-19 patients have an even higher risk of acquiring MDR bacterial infections, leading to a mortality rate even higher than that conferred by COVID-19 alone.