Antibiotic-resistant
MRSA, seen here in a culture held by medical laboratory scientist
Danielle Lucore, is among the top challenges for infectious disease
specialists.
For
years, physicians and scientists around the world have documented an
increase in the number of drug-resistant bacteria. Some new strains,
such as the New Delhi strain of E. coli that recently emerged from
India, show resistance to all existing antibiotics. With few new
antibiotics in the development pipeline, many in the medical community
have declared the situation dire.
“This
is a public health emergency across the nation,” says Dr. Robin Trotman,
CoxHealth infectious disease specialist and the physician who oversees
the health system’s antibiotic stewardship program.
In
2008, CoxHealth launched the program, modeled on the successful programs
found at larger health care institutions in major cities, to help
bridge the gap between drug-resistant bugs and the lack of medicines to
fight them.
By
applying principles of antibiotic stewardship – matching the most
appropriate antibiotic to each infection, carefully dosing the drugs to
balance their effectiveness with cost and patient outcomes, and
researching alternative therapies – the program aims to prevent the
emergence of antibiotic-resistant infections at CoxHealth.
Pharmacist
Melissa Steenhoek spends her days working on the program, acting as a
steward of the system’s formulary. “I constantly review data and make
recommendations for antibiotic selection and dosing to discourage
antibiotic resistance and give our patients the best possible outcomes
while decreasing costs,” she says.
Bacteria develop resistance over time. During prolonged or inappropriate antibiotic exposure, they adapt to overcome the very drugs created to fight them.
“Each
antibiotic has a different spectrum of infection it covers,” says
Steenhoek. “If a broad-spectrum antibiotic is selected when a more
narrow-spectrum antibiotic would be just as effective, the
broad-spectrum drugs become overused, and resistance develops.”
But by
carefully overseeing the use of antibiotics, reviewing individual cases
and monitoring the resistance problems that most hospitals are dealing
with, Steenhoek and Dr. Trotman are able to keep CoxHealth ahead of the
curve – and in some cases, change our trajectory.
One
example: their work regarding MRSA infections with reduced Vancomycin
susceptibility at CoxHealth. A poster the pair created on the topic was
presented at a national conference hosted by the Infectious Diseases
Society of America, and Dr. Trotman recently spoke at a conference
hosted by the Carolinas Antimicrobial Stewardship Effort and Wake Forest
Medical Center on the issue.
Vancomycin
is one of the most commonly used antibiotics in the hospital setting,
and the treatment of choice for MRSA, or methicillin-resistant
Staphylococcus aureus infections. Dr. Trotman says research shows that
MRSA is becoming resistant to Vancomycin – a dangerous development.
Through the antibiotic stewardship program, he and Steenhoek looked at
how to more appropriately use Vancomycin in the hospital, to reduce this
level of resistance.
They
developed a program that included using Vancomycin in higher doses to
treat more difficult infections, stopping its use when it wasn’t needed
and educating other pharmacists on how to more appropriately dose it.
After a couple of years using this model, they compared the sensitivity
of MRSA to Vancomycin before this project to its sensitivity afterward.
They were able to show that, while most hospitals have seen an increase
in MRSA infections with reduced susceptibility to Vancomycin, CoxHealth
saw fewer of these cases.
“In
essence, MRSA at our hospital and in our community is more sensitive to
Vancomycin than it was before our program started,” says Dr. Trotman.
“We’ve changed the ecosystem of the hospital.”
While
the main goal of the program is improving patient outcomes, changing the
way the system uses antibiotics also saves the system money. Developing
best practices and order sets for the use of antibiotics in the
hospital and working to keep CoxHealth in compliance with the many
regulatory requirements that touch on this issue are an important part
of this process. While a specific dollar amount tied to the CoxHealth
Antibiotic Stewardship Program is not available, national research shows
that these programs typically save hundreds of thousands of dollars in
the long-term.
Currently,
the antibiotic stewardship program is focused on inpatient antibiotic
use, but Steenhoek is beginning to collect data through some CoxHealth
walk-in clinics. The goal is to eventually expand the program – and the
program’s successes – to the outpatient setting.
Says
Dr. Trotman: “This is a progressive program for a community hospital. We
have outcomes and metrics that show we’re making a difference.”
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