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Guardians of the Galacardins
As an Infectious Diseases Society of America Center of Excellence, The Houston Methodist Antimicrobial Stewardship Program embodies our mission to solve the toughest problems confronting patients.
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After 21 U.S. companies joined together to produce 2.3 million doses of penicillin in preparation of the D-Day invasion of Normandy in 1944, penicillin became known as the war’s “miracle drug.”
Eighty years later, the threat of antimicrobial resistance (AMR) is realized on the battlefield, as evidenced by the recent case of a Ukrainian soldier diagnosed with six distinct extensively drug resistant infections. Extensively drug-resistant bacteria, or XDR bacteria, are organisms resistant to all, or almost all, approved antimicrobial agents.
Muhammad Yasser Alsafadi, MD
My mantra for 2023 has been ‘from good to great’ and my personal stewardship philosophy is really a data driven, collaborative effort empowered by a global perspective equipped with precision medicine tools that improve patient outcomes while decreasing costs and antimicrobial resistance. That's what guides me on a daily basis.
Muhammad Yasser Alsafadi, MD
Antimicrobial Stewardship Program medical director at Houston Methodist
AMR isn’t only a concern for those at war. The efficacy of antimicrobials — including antibiotics, antivirals, antifungals and antiparasitics —has diminished globally, and the development of new antimicrobials is severely lacking. In 2019, only 32 antibiotics in clinical development were identified by the World Health Organization as targeting their priority pathogens. Of those, a mere six were considered innovative.
AMR looms large in healthcare. The estimated national cost to treat infections caused by six multidrug-resistant germs frequently found in healthcare is substantial—more than $4.6 billion annually, according to a collaborative CDC study. The need for antimicrobial stewardship in healthcare has become critical. Leading the charge in advocating for, and recognizing excellence in, antimicrobial stewardship is the Infectious Diseases Society of America (IDSA).
IDSA is comprised of physicians, scientists and public health experts who specialize in infectious diseases and have come together to “improve the health of individuals, communities, and society by promoting excellence in patient care, education, research, public health, and prevention relating to infectious diseases.”
In 2019, IDSA awarded 23 institutions, including Houston Methodist, the designation of Antimicrobial Stewardship Centers of Excellence (CoE). The CoE program recognizes institutions that have developed stewardship programs demonstrating excellence and meeting rigorous standards aligned with national guidelines, including the IDSA-SHEA guidelines and the Centers for Disease Control and Prevention's Core Elements.
The fundamental requirements of the CoE program prioritize an institution's capacity to implement stewardship protocols aimed at enhancing infection treatment outcomes and minimizing adverse events linked to antimicrobial use. CoE applications are evaluated by a distinguished panel of IDSA member leaders who assess them against the core criteria, providing recommendations for the designation.
“Antimicrobial resistance is one of the greatest threats facing healthcare on a global, national and individual level. In fact, antibiotic-resistant infections are the third leading cause of death in this country. IDSA is fighting antimicrobial resistance on every front, including research, education, training, and through our policy efforts. We are proud to partner with each of the institutions that have received the Centers of Excellence designation in turning the tide against antimicrobial resistance,” said IDSA President Cynthia Sears, MD, in a press release.
Possessing a CoE designation signifies an institution has the policies and processes in place to deliver high-quality stewardship services consistently, execute novel stewardship principles, and demonstrate a high-level commitment to improving antimicrobial use and reducing resistance.
At Houston Methodist, the Antimicrobial Stewardship Program (HM ASP) is dedicated to creating, executing, and assessing impactful and enduring patient care strategies that enhance the effectiveness of antimicrobial usage throughout Houston Methodist. By comparing the utilization and interventions of antimicrobial agents within our organization and across the nation, the HM ASP provides personalized feedback at the entity level, enabling targeted interventions with more effective metrics across the hospital system.
The HM ASP consists of clinicians at every site and at least one clinical pharmacist and one medical director assigned to every campus to oversee core program goals and initiatives. First-hand experience and routine assessment mean the program evolves to become more effective in real time. Best practices created on-site might be adopted systemwide, while system-level discussions result in implementation of others. Key components in the day-to-day operations include prospective audit and feedback: reviewing broad-spectrum antibiotic use, making recommendations on tailoring use for optimal therapy, optimal duration and optimal dose for the right indication. Surveillance to track important outcomes, like C. difficile infections and resistance patterns is also crucial.
Annual charters and strategic planning provide short-term goals as well as long-term visions for the HM ASP. The goals for the current year include implementing improved penicillin allergy assessments across the system; surgical prophylaxis and picking optimal drugs and appropriate weight-based dosing in the preop population; and implementing Bayesian dosing: using patient data to estimate a patient's ability to absorb, process and clear a drug. Making sure the needed infrastructure is in place and that all HM facilities are participating are the priorities.
The team at Houston Methodist, led by Muhammad Yasser Alsafadi, MD, Antimicrobial Stewardship Program medical director, is ensuring that HM ASP not only meets the minimum requirements for the CoE designation, but that they surpass it.
“My mantra for 2023 has been ‘from good to great’ and my personal stewardship philosophy is really a data driven, collaborative effort empowered by a global perspective equipped with precision medicine tools that improve patient outcomes while decreasing costs and antimicrobial resistance. That's what guides me on a daily basis,” Alsafadi said.
“Stewardship is not one person's job, it’s everyone’s job,” said Natalie Finch, PharmD, Clinical Pharmacy Specialist - Antimicrobial Stewardship. At Houston Methodist there is continual collaboration between clinicians, ID specialists, and primary teams and pharmacists on the units. “We learn a lot from our clinical pharmacy staff and hope through education and other measures that we’re reaching other clinicians and ingraining better recommendations in their day-to-day practice,” Finch said.
Their diligence and hard work are paying off. While it may seem like the battle is insurmountable, HM ASP is making progress. For example, in 2021 a protocol was implemented allowing pharmacists to independently order a PCR test for Methicillin-resistant Staphylococcus aureus (MRSA). If the test results are negative, the pharmacist can discuss deescalating anti-MRSA therapy with the treating physician. This protocol has resulted in a significant reduction of the use of anti-MRSA antibiotics.
Giving physicians such an effective tool for increasing accuracy in antimicrobial prescribing is invaluable.
“Antibiotics can feel like a safety blanket. They make people feel good because they protect the patient. But it's a sword. The benefit in patients who are actively infected comes with the risk of resistance. So, we're constantly walking the line — balancing those risks and benefits. Our wins really come with using the narrowest spectrum agent possible with the shortest duration possible to accurately, and adequately, treat the infection while minimizing risks,” said Shivani Patel, PharmD, Pharmacy Administrative Specialist, Antimicrobial Stewardship.
U.S. Antibiotic Awareness Week is November 18-24, 2023.
Heather Lander, PhD
August 2023
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