Q&A: How COVID-19 Might Affect Antimicrobial Stewardship Programs

Antimicrobial stewardship programs were already going through some big changes before COVID-19 struck. The US Centers for Disease Control and Prevention and the Joint Commission both want hospitals to have stewardship programs with measurable metrics. Just how-or even if-COVID-19 patients should be treated with antibiotics is still being worked out, Katherine Perez, PharmD, tells Infection Control Today^®. One thing COVID-19 has done that might make Perez’s job easier in the future is the focus it places on hand hygiene. “I would certainly hope that that continues even once we get to whatever the new normal will be, and that hand hygiene will become a part of the new normal, and in a far bigger way than it has in the past,” says Perez.

Infection Control Today^®:  How do you see antimicrobial programs functioning in the future after this COVID catastrophe? What kind of changes do you expect?

Katherine Perez, PharmD: Well, it’s something that we’ve been dealing with on an ongoing basis certainly since the pandemic has come to Houston particularly since the beginning of March. I think we knew that there would be a lot of overuse of antibiotics, but we certainly weren’t 100% as to whether or not that was appropriate. You know, we’ve had a lot of initiatives in place for patients who end up with viral infections and actually intervening to try to get antibiotics taken off because they don’t need them. We know they have rhinovirus they just need some chicken soup. But with COVID-19 virus, it’s really not known. And what we've seen in the literature to date has painted a picture that would scare you from not using broad spectrum antibiotics. But again, you know, those are always going to be the patients who were sicker, who weren’t going to have a better outcome to begin with. And, so, it’s really hard to know right now what the right answer is. For the most part, I think everyone is waiting on data to be published and have peer-reviewed data that can actually help guide whether or not we should be using antibiotics while patients are in-patient with COVID-19, or whether there are certain biomarkers that we can use to indicate whether or not we can start or stop antibiotics.

ICT^®: Do you think this will carry over to the post-COVID era? Using antibiotics almost as a failsafe for a viral problem?

Perez: I don’t think so. I don’t think that I truly believe that it has been this extraordinary situation that has really, you know, put us in a place that we are completely out of our comfort zone in terms of antibiotic use. And I think that once we can get to a place where we can be in our comfort zone or have a diagnostic to show that a patient doesn’t have the coronavirus, I think that providers and clinicians are likely to revert back to what was normal prior to COVID-19. But I can say at least here in Houston Methodist Hospital, whenever there is a patient and you’ve ruled out COVID, their antibiotic use tends to be similar to what it was when we were putting in all of our stewardship interventions. And again, we’re still continuing those stewardship interventions. I think that as long as we keep up with that, hopefully we can keep our antibiotic numbers at least in line with the census with respect to COVID-19.

ICT^®: Leaving COVID-19 aside for a moment, did you see antimicrobial programs evolving?

Perez: I certainly think that the legislation that CMS endorsed and put forward in their Conditions of Participation for the antimicrobial stewardship requirement certainly helped to put an antimicrobial stewardship program far more up front, not just center, of the administration and hospital leadership’s agenda. Whereas an antimicrobial stewardship presentation was often a nice-to-have or an add-on to our leadership’s agenda…. Anytime we would report to the board, it was always a nice update, but it was never anything that was required. It was never anything that we needed to demonstrate certain metrics about. And now that’s changed. So now I see that that has been added to the docket just like infection control is, just like a substance committee is, or just like skin and soft tissue infections, post-surgical items have been. This has just become one of those programs that does actually have a seat at the table and is actually responsible and accountable to our leadership and has metrics to meet. I certainly have seen that evolution, which is very fortunate, because it’s I think what many of our of the antimicrobial stewardship program leaders have been hoping for and wanting for decades at this point.

ICT^®: Hasn’t this been a recent development spurred by the CDC’s increased interest in antimicrobial stewardship programs?

Perez: We really picked up the pace, at least here at Houston Methodist Hospital, with formalizing our committee structure and actually having a medical director and having the infrastructure set up to truly have an antimicrobial stewardship team in 2016. And that was one of the very first proposed conditions of participation that were published. Now, they were still proposed throughout 2017 and 2018, and then we got to 2019. And they finally got finalized. But by the time they were finalized, we were certainly teed up and ready to go. And we were already an agenda item on a lot of those leadership meetings, and now it’s just become even more important. But it did certainly get us the attention that we needed and has provided us with the time to become the antimicrobial stewardship program that that this type of facility should have.

ICT^®: How do you decide who’s on the antimicrobial team?

Perez: We have a committee that is actually the leadership of each hospital. We have eight hospitals in our system. Our system committee includes our leadership from systemic infection control, our leadership from system quality, our leadership from a system administrative leadership position, and then every medical director from each facility and every lead pharmacist from each facility, and then myself. And then that’s kind of the big umbrella and then every hospital has kind of their boots on the ground, and every hospital has their pharmacist lead, their medical director lead. Then they have maybe an intensivist and a hospitalist and perhaps one of the charge nurses who works on the floor with high utilization. And the model that we try to adopt is, we pick several items of interest at the system level. And say there’s a couple of hospitals that have a big problem or are really working hard to address C. diff. So we kind of put that on our list. And then let’s say we have another couple of hospitals that really want to work on improving asymptomatic bacteria. We’ll put a couple of those on our list. And then we help craft the interventions. We help craft the guidance for each of those system hospitals. Then that information gets filtered down to the boots on the ground and implemented in the way that best suits their resources and their institutional culture. And it’s been working really well for us. We have a great reputation. Certainly, if you want something to get done, they say, “Oh, the stewardship team should be able to do that!” Which is always nice. It’s a double-edged sword, yeah, but it has been a model that’s worked really well for us. And at every hospital, we do ensure that there are representatives that are truly the bedside clinicians that are truly the people who we can’t just tell them what to do. We have to bring them to the table and have them be part of those conversations. And if, for whatever reason, we’re focusing on a surgical site infection for a quarter of the year, then we bring in ad hoc clinicians to serve on behalf of those groups in a way that allows them to roll off and roll on as needed. Because again, you know, we don’t want to waste anyone’s time. We don’t want to have people who are truly in the ORs all the time, having to come to a meeting about C. diffor something like that, where they really can’t weigh in on those different populations.

ICT^®: Are infection preventionists part of your antimicrobial stewardship program?

Perez: Yes, they are, but they are separate. Just as I mentioned, we have a system and a microbial stewardship program. There is a system for the infection control group, as well. And I attend those meetings. And then vice versa. My counterpart, essentially the lead infection control practitioner for the system, attends our system programs, as well. And then at the local level, that happens as well. There are a couple of our hospitals that are maybe 200 bed hospitals that actually join both meetings within the same hour. And they’ll split the first half hour and focus it on infection control and then the second half hour and focus that on stewardship or vice versa. They kind of just go back and forth. And that’s actually really nice because it gets a far larger crowd in the room. But it’s needed because, again, we have 1000 plus hospital beds here in our flagship hospital. It would be impossible to join those two within any conceivable timeframe that would keep anyone’s attention. We do have to have them separated, but we do attend each other’s meetings and we are standing members. We do have standing agenda items on each other’s meetings where we provide an update.

ICT^®: We talked a little bit about the CDC throwing its weight behind antibiotic stewardship programs. Didn’t the Joint Commission do the same thing within the last few years?

Perez: They did. And they actually implemented it into their standard in 2017 which I think was a big reason that we saw a large push for leadership engaging in antimicrobial stewardship programs. We at our hospital here at Houston Methodist Hospital are accredited by DNV [Det Norske Veritas] and DNV actually followed suit to what the Joint Commission had implemented. They’ve implemented pretty much the exact same type of requirements and expectations. And so those are really the guidelines that we’re abiding by. And by the time DNV implemented those, we were already there.

ICT^®: What do you suppose made the CDC and Joint Commission and DNV get more serious about antimicrobial stewardship programs? Did you see this coming down the pike?

Perez: Well, you know, once the CDC published its first antibiotic resistance threat report in 2013, I think that’s really when the writing was on the wall, essentially. I remember when I saw it, and I was like, “Oh, my goodness! This is awesome!” Because what that did was it really put a spotlight on antibiotic resistance in a way that it never had before. And nobody had ever really acknowledged what a big problem it was outside of our small stewardship or antimicrobial infectious diseases community. And I don’t think that we were even in a position to elaborate in the way that that report was able to. Because it was able to have so much information and it really painted a fantastic picture of what was happening. And I think that after that was published and after President Obama launched an executive order to create the national action plan to combat antibiotic resistance, and put together a task force, I think that all of those things coming together is what has set us up for what we saw in the CMS Conditions of Participation.

ICT^®: Do you think COVID-19 will make people more conscious of hand hygiene? And will that make your job easier? 

Perez: I certainly hope so. I think that that’s to be determined at this point. But I certainly know a lot of people that don’t work in a hospital who are now far more conscious of washing their hands at every opportunity, which I think is fantastic. I know here in the hospital our hand hygiene has been tremendous. We’ve implemented other types of places where you can have a hand washing station that’s actually portable. So not everyone kind of congregates around the same sinks and whatnot. And I think that that’s been really telling of the institution’s commitment to ensuring social distancing and also promoting hand hygiene. And I would certainly hope that that continues even once we get to whatever the new normal will be, and that hand hygiene will become a part of the new normal, and in a far bigger way than it has in the past. And I certainly would expect that that would help with our jobs moving forward, but I certainly don’t have a crystal ball.

ICT^®: So, if I may try to paraphrase what you told me: COVID-19 will not have that much of an effect on antibiotic stewardship programs. However, those programs were already going through some pretty significant changes.

Perez:So COVID-19-to say that it won’t have an effect on stewardship programs. I don’t know that I would go as far as to say that. I would say, for patients with COVID-19, I think the jury’s still out as to how we should be using antibiotics in those patients and what the risk of a secondary bacterial infection truly is. And that type of information has not been made available, at least not in huge amounts at this time. In the next several months, I hope that we will start to see that information come out and have been peer reviewed, and to certainly provide some guidance as to whether or not we should be using antibiotics to prevent bacterial super infection. Aside from COVID-19 patients, I’ve been very encouraged by our clinicians in that they tend to adhere to the antimicrobial stewardship interventions and recommendations that we continue to make, because patients are not COVID positive. And just because they’re in the hospital during a time of the COVID pandemic, doesn’t mean that they need other antibiotics. I certainly have been encouraged by that. And with respect to the legislation and all of the different political attention that antimicrobial stewardship programs have received, I certainly think that they are all steps in the right direction. And I really hope that one of the next things that we do is actually try to find a way to reimburse drug manufacturers to actually have a reliable supply of research and development into new drugs for any infection. So many companies are now having to file for bankruptcy, because no one wants to use the drug. And again, it’s one of those things: Why would a manufacturer create a drug and then have someone like me restrict it? I really think that it’s the government’s responsibility to step in and truly highlight the incentives for that type of research and development.

This interview has been edited for clarity and length.