Antimicrobial stewardship program aims to reduce antibiotic resistance with better targeted antibiotics
by Mary Silva
Even as Alexander Fleming accepted the Nobel Prize in 1945 for his discovery of penicillin, he warned of the dangers of misusing antibiotics. In the decades since, we have increased our antibiotic arsenal by the hundreds, saving countless lives. But as Fleming predicted, the misuse of these drugs has given rise to “superbugs” – bacteria resistant to even the most potent treatments.
Mediating the relationship between man and microbe is what infectious disease specialist David Haslam, MD, will focus on in his new role at Cincinnati Children’s. Haslam joined the Division of Infectious Diseases in July to launch an Antimicrobial Stewardship Program at the medical center.
RESISTANT INFECTIONS ARE ON THE RISE
Haslam takes on this role as part of the medical center’s commitment to ensuring the safety and well-being of patients. Like hospitals everywhere, we grapple with infections that have grown more virulent and stubborn.
“The risk of hospital-acquired infection is actually decreasing, but the types of infections are worse,” Haslam says. “The bacteria we are seeing are often resistant to many antibiotics, and in some cases almost all antibiotics.”
It is a problem brought on largely by our overuse of antibiotics – usually, says Haslam, giving a drug that is not targeted well enough, or in a dose that is not appropriate for the infection.
“Our goal is to get patients on the right antibiotic at the right dose for the right amount of time. We believe that by being more focused and rational in our choices, we might decrease antibiotic use and decrease resistance rates.”
AUTOMATION TO THE RESCUE
With our daily inpatient census averaging more than 400 children, keeping tabs on antibiotic dosage in the medical center is no easy task. The Antimicrobial Stewardship Program has recruited a powerful assistant for the job – a software program called VigiLanz.® Cincinnati Children’s is the first pediatric hospital in the country to deploy the program.
When fully operational, VigiLanz will gather information from all of the hospital’s electronic medical records, order entries, computerized laboratory and pathology reports, and more. “It monitors in real time everything that’s happened to every patient in the hospital,” Haslam says. “We can look at every positive culture from every sample taken from every patient.”
Haslam scrolls through a computer screen where thousands of lines of entries reveal what each patient is infected with, what drug the child is being given and in what dose. “We have 3,000 positive cultures from patient samples in just the last few months,” he says. The list includes organisms the patients came into the hospital with as well as those they acquired while here, he explains, adding that a major focus of the Antimicrobial Stewardship Program will be on infections acquired while in hospital.
A PERFECT STORM FOR INFECTION
“A lot of what we do with and for patients suppresses the immune system and puts them at risk of infection,” Haslam says. “We have the country’s busiest bone marrow transplant unit; we treat many children who have cancer; we have an active operating room. Our patients do very well, but because of these interventions, children are at higher risk of infection.”
And here, as at all other hospitals, the infections children are at risk of acquiring tend to be what Haslam calls “the most nasty bugs,” the ones most resistant to treatment.
KILLING BUGS SOFTLY
Through the Antibiotic Stewardship Program, he hopes to decrease exposure to the broad-spectrum “big gun” super antibiotics and instead use more targeted treatments.
“We want to make sure we don’t put patients at risk, of course,” Haslam says. “But we believe we can decrease the potential downside by choosing antibiotics that are likely to be just as effective, but have less risk of increasing antibiotic resistance.”
If a patient is being treated with a drug or dose that’s likely to be ineffective or overly broad, Haslam and his team of clinical pharmacists will step in – but gently.
“Some hospitals just say, ‘You can’t use that drug.’ Our approach will be, ‘You might want to consider,’” he says. “We hope physicians will view this as bringing a lot of potential benefit.”
CLINICAL PHARMACISTS PLAY KEY ROLE
The hospital’s clinical pharmacists will play a key role in the Stewardship Program. They are the first to know if a drug is not working well and the most knowledgeable about alternatives. “The pharmacists offer a wider perspective on choice and dosing of drugs. We rely on them a lot,” Haslam says. “We’re fortunate to have clinical pharmacists involved in the care of essentially all admitted patients.”
Haslam is working closely with Joshua Courter, PharmD, to run the Antimicrobial Stewardship Program and implement the VigiLanz system. Because clinical pharmacists are embedded with the hospital’s care teams, says Haslam, they are well-positioned to recommend alternative medications if needed.
Although in its early stages, Haslam is optimistic about the Antimicrobial Stewardship Program’s potential to bring about better outcomes for patients, short and long-term.
“We think there is no downside. We want to show that by narrowing our use of antibiotics, we are not putting our kids at risk and are in fact improving outcomes overall.”
Replacing broad-spectrum “big gun” antibiotics with better targeted treatments will improve outcomes and lower the risk of antibiotic resistance, says Dr. David Haslam.