How Antibiotic Stewardship Programs Play a Vital Role During Public Health Crises

As coordinator of the University of Maryland Medical Center’s (UMMC) antibiotic stewardship program, infectious diseases pharmacist Emily Heil leads a team of medical professionals dedicated to combating the spread of antibiotic-resistant superbugs while optimizing patients’ antibiotic treatments. Infections from resistant bacteria have been on the rise, and deaths are projected to skyrocket in the coming decades.

This interview with Heil, who also serves on the board of directors of the Society of Infectious Diseases Pharmacists, has been edited for clarity and length.

Q: When did the University of Maryland Medical Center start its stewardship program? And why?

A. UMMC’s antibiotic stewardship program began in the early 2000s. We’re lucky to have strong support from our chief medical officer and leadership team, who recognize the importance of antibiotic stewardship to public health and patient outcomes. And that support—from leadership and fellow practitioners alike—has only strengthened in recent years as we’ve seen increasingly scary evolutions of resistant pathogens, and more and more patients with infections that are extremely difficult or sometimes impossible to treat.

Because all antibiotic use contributes to the emergence of resistance, antibiotics are really the only kind of medicine I can think of where one doctor’s choice to use it can affect the ability to treat another patient. Antibiotics truly are a shared public resource, and stewardship programs are essential to managing them.

Q: What does antibiotic stewardship look like at UMMC?

A. Our program has two buckets: stewardship at the individual patient level, which helps to optimize treatment of patients in the hospital day to day; and what I call the “big picture work,” which identifies trends and opportunities for hospitalwide improvements to care.

At the individual level, we’re looking at cultures and reports from the microbiology lab to make sure that each patient is getting the right drug at the right time and for the right length of time for their pathogen. A lot of what we’re doing is changing therapy to be as effective as possible while helping both to reduce unnecessary time on antibiotics and avoid the potential side effects of antibiotic treatment.

In terms of the big picture, we take a longitudinal perspective—looking at antibiotic use across the hospital over time. By doing that, we’ve been able to identify increases in certain classes of antibiotics. For example, several months ago we found an increase in the use of carbapenems, which are antibiotics used primarily to treat multidrug-resistant infections. This was concerning because carbapenems are one of what we call our “big gun” antibiotics, which we want to make sure we’re reserving for when they’re really needed. So, we did more research, and as a result we were able to hardwire some changes into our system’s electronic health records aimed at addressing inappropriate use. We’ll go back in a few months to look at the data, see what the effect was, and make updates as needed.

Q: How has the coronavirus pandemic affected UMMC’s stewardship efforts?

A. I consider myself and our program lucky because our stewardship efforts have remained adequately resourced during the pandemic. I’ve heard horror stories from infectious disease colleagues about their stewardship programs being cut entirely, or their team being furloughed or dispatched to other areas indefinitely. That’s troubling, because the long-term implications of having to pull back in the fight against superbugs are hard to fathom.

When COVID-19 first hit, our stewardship team took the lead on establishing treatment guidelines for all of UMMC. Because we already had a good stewardship infrastructure and guidelines in place, which our medical staff trusted and was used to referring to regularly, we were able to quickly and effectively distribute COVID-19 updates—especially in the early days of the pandemic, when there were still a lot of unknowns, and new data and recommendations were coming through daily.

Q: Pew’s research shows that, nationwide, about half of all COVID-19 patients who were hospitalized from February through July received antibiotics. How does that compare to what you saw at UMMC? And have you seen any changes in antibiotic prescribing in your hospital over the course of the pandemic?

A. The 50% figure tracks with what we’ve seen at UMMC. However, we’ve seen a lot of variance over the course of the pandemic. In March and April, out of an abundance of caution, about 90% of our COVID-19 patients were receiving antibiotics. At the same time, though, hospitalwide antibiotic use was down because we had fewer patients overall and we were delaying nonurgent procedures due to the pandemic. Then, as we got into May and June, we were starting to see studies showing that rates of COVID-19 patients who also had bacterial infections were relatively low, so the antibiotic prescribing rate among most COVID-19 patients went down. But around that time, we also started to have an increasing number of COVID-19 patients who had been in the hospital for an extended duration, and many of these patients were on ventilators and had catheters. That put them at an increased risk for hospital acquired infections, ultimately increasing antibiotic use again.  

So, a lot of variables have been at play. And through it all, our stewardship team was involved—keeping up our normal interventions and helping to optimize antibiotic treatment as needed.

Q: Nearly a year into the COVID-19 pandemic, what would you say are the lessons learned? Do you have any key takeaways for what’s worked well so far? And what else is needed to help ensure that when the next public health crisis hits, antibiotics are used appropriately and patients receive the best care?

A. I have three main takeaways.

First, it’s essential to continue to prioritize high-quality research, even during the height of a crisis like COVID-19. Early on, there were so many unknowns, and the only way to answer those unknowns is through good clinical trials and well-designed, systematic studies. You have to take a deep breath, and put the panic aside, because research is the key to understanding what’s going to work for patients—and to improving care as quickly as possible.

Second, we need to give infectious disease clinicians, both physicians and pharmacists—who are central to stewardship efforts—the credit they deserve. They’re essential to combating this and future pandemics, yet the reality is that infectious diseases is struggling as a profession. It’s the lowest-paid physician specialty. Reimbursement is low. And students entering medicine are not pursuing infectious disease. That’s a problem for humanity in the long term.

Third, flexibility is key. We’re learning something new every day of this pandemic: I have a set of slides on COVID-19 treatment, and I’ve probably updated it nearly 100 times already. Being able to adapt quickly, and then communicate and implement changes efficiently, is essential.