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COVID-19, antimicrobial stewardship and preparing for the next outbreak

Emily Spivak, MD, MHS, FIDSA
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Everyone in ID has been called to serve during the COVID-19 pandemic in a variety of critical ways, and antimicrobial stewards like me are no exception. Using our expertise to help guide the optimal use of COVID-19 therapeutics continues to be a complex undertaking made more problematic by a wide variety of challenges. These include inadequate supplies, limited numbers of health care workers, constantly evolving data, political interference and the unique hurdles involved in reaching underserved populations and promoting equitable use of therapy.

Our efforts in partnership with local public health agencies have saved lives and averted hospitalizations. But what was happening while our attention was diverted by COVID-19? What important elements of patient care and public health fell through the cracks? And how can we better equip antimicrobial stewardship programs for the next outbreak? ID experts must answer these questions and ensure that federal, state and local leaders and health care institutions apply our expertise and lived experience to better prepare for the next emergency.

Supporting the pandemic response

As the director of antimicrobial stewardship for the University of Utah and the Salt Lake City VA, I was proud to partner with experts across our state and our state health department to develop strategies to optimally distribute and use COVID-19 therapeutics. We developed an evidence-based algorithm to assess a patient’s risk for serious disease that includes factors such as underlying conditions, age and race/ethnicity in order to prioritize therapy to those at highest risk of severe COVID-19. Our work as antimicrobial stewards was crucial to our success in directing therapy to reduce emergency room care and hospitalization.

We also devised innovative strategies to reach our rural residents and those with less access to health care, including outreach efforts where nurses contact patients with positive test results to connect them with treatment if they qualify. This direct approach helps ensure patients do not fall through the cracks or delay treatment, even if they cannot see their regular medical provider or are unaware they are high risk and eligible for treatment.

Our stewardship team led efforts to evaluate treatments for COVID-19 in clinical trials, develop treatment guidelines, and educate providers and leaders as data rapidly evolved. We started a “COVID pager” staffed by our team to answer clinical, testing and treatment questions, and provide diagnostic stewardship oversight of rapid COVID-19 tests when these were in short supply. We regularly met with leadership and clinical champions to update them on the latest research and treatment efforts. We were also a regular public face educating the community. All these efforts, in addition to our role advising statewide efforts to provide outpatient COVID-19 treatment, built integral relationships and cemented our expertise and value to the institution, opening up conversations for future investments in our stewardship program.

Impacts on traditional stewardship

Our successes were many, but at what cost? Every hour that our stewardship team — already a small one — spent on COVID-19 was an hour we could not spend on traditional stewardship. For several weeks in January 2022, we redirected efforts from traditional stewardship activities reviewing antibiotics to focus on outpatient COVID-19 treatment. We saw increases in outpatient antibiotic use for viral respiratory conditions and antibiotic use for patients hospitalized with COVID-19 early in the pandemic. But we had limited resources to address these increases. How many suboptimal antibiotic choices did we miss? How many avoidable side effects for patients and how much new antibiotic resistance did we allow to develop?

Going forward, how can we better position and arm stewardship programs to leverage their expertise for future outbreaks or pandemics while ensuring we have the dedicated workforce to maintain our critical work to address antimicrobial resistance? A 2018 study found consistent gaps between recommended and existing MD and PharmD staffing levels, and that was based upon our smaller pre-pandemic workload. This study further found that a 0.50 increase in full-time equivalent support predicted a 1.48-fold increase in the odds of demonstrating effectiveness. But we are moving in the wrong direction. As COVID-19 further stressed hospital budgets, resources were diverted from stewardship and, in some cases, stewardship staff were furloughed or saw their positions eliminated.

Where we go from here

We need to recruit more people into ID and stewardship, and we need to ensure all hospitals have the resources to meaningfully implement stewardship to meet the footprint of their clinical operations. Two different bipartisan bills spearheaded by IDSA and under consideration in Congress could help. The Bolstering Infectious Outbreaks (BIO) Preparedness Workforce Act would provide loan repayment to health care professionals who work in bio-preparedness (including stewardship) or provide ID care in underserved areas. The Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Act would provide grants to hospitals — prioritizing rural, critical access and safety net hospitals — to support their stewardship programs, in addition to strengthening antibiotic and antifungal development.

We have a unique moment to use the national spotlight on ID to drive lasting policy changes for our field and the threats we face, like antimicrobial resistance. But change won’t happen without all of us using our expertise and raising our voices — exactly as we have in response to COVID-19. You can add your voice today to urge Congress to advance the BIO Preparedness Workforce Act and the PASTEUR Act. Our lived experiences and hard-earned lessons during this pandemic can make a difference.



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