Monday, January 23, 2012

Fighting our smallest enemies

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.”