Infections are a major complication of cancer treatment, so timely and appropriate antimicrobial therapy is critical for optimal patient outcomes. However, the large number of anti-infectives and the growing problem of microbial resistance have complicated prescribing. Establishing an antimicrobial stewardship program that can provide guidance and oversight of these medications in acute-care hospitals and other healthcare settings is increasingly encouraged.
Memorial Sloan Kettering has had an antibiotic management program (AMP) since 2001, which has the distinction of being one of New York City’s oldest antimicrobial stewardship programs. Susan Seo, an infectious disease (ID) physician and the program’s founding director, continues to lead the program. Other key members include full-time ID clinical pharmacists and a data manager. The AMP strives to ensure the optimal selection, dose, and duration of antimicrobials for effective treatment or prevention of infection while minimizing side effects and risk for subsequent resistance.
Meet the Team
Susan K. Seo, MD, FACP, FIDSA
Director, Antibiotic Management Program
Infectious Diseases Service
Nina Cohen, PharmD, BCPS, AQ-ID
Clinical Pharmacy Specialist
Alla Paskovaty, PharmD, BCPS, AQ-ID
Clinical Pharmacy Specialist
Marco Scipione, PharmD, BCPS, AQ-ID
Clinical Pharmacy Specialist
Prior approval and post-prescription review: The primary goal of this process is to provide a system for rapid and rational antibiotic approval. Review guarantees that each patient receives the appropriate therapy, including dosing and duration. The AMP also performs targeted reviews to reevaluate antimicrobial therapy based on clinical, laboratory, and microbiologic data that are collected during a patient’s hospital stay.
AMP website: The AMP maintains a website on the MSK intranet, which serves as a repository for all evidence-based antibiotic and antifungal guidelines that have been developed for the institution. This site serves as a valuable resource for hospital staff. Some of the guidelines developed in partnership with various departments include Outpatient Fever & Neutropenia, Surgical Prophylaxis, Allogeneic and Autologous HSCT Prophylaxis, and Pediatric Antimicrobial Drug Dosing.
Education: Education is an important component of antimicrobial stewardship. ID fellows have an opportunity to work with the AMP during their microbiology/AMP/infection control rotation during their first year. The AMP also gives talks related to antimicrobial stewardship within the institution.
IDSNY Pre-Meeting Workshop for ID Fellows: Since 2013, AMP Director Susan Seo has been co-director for the Infectious Disease Society of New York (IDSNY) pre-meeting workshop on antimicrobial stewardship and infection control, which is held each spring. This is a half-day course created in partnership with Montefiore Medical Center for regional ID fellows. The program consists of interactive case-based learning in which solutions are discussed in an open forum among ID fellows and a local panel of experts from up to 12 area hospitals. The opportunity to supplement training in antimicrobial stewardship and infection control as well as to meet well-recognized experts in both fields has led to positive response from past attendees.
Research: The AMP works collaboratively with Infection Control, Clinical Laboratory Medicine, Pharmacy, IT, and various medical and surgical oncology services. Areas of clinical research include investigating stewardship methods to optimize antimicrobial use (such as a multicenter study evaluating post-prescription review and feedback), studying the relationship between antimicrobial exposure and clinical outcomes, and looking at the interplay between microbiologic testing and antimicrobial prescribing. Past ID fellows have worked with the AMP on stewardship-related projects and have presented their findings at local and national meetings. Incoming and current fellows, as well as other trainees, are welcome to engage in research projects with the AMP.
- Paskovaty A, Pflomm JM, Myke N, Seo SK. A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century. Int J Antimicrob Agents 2005;25:1-10.
- Cohen N, Mihu CN, Seo SK, Chung D, Chou J, Heller G, Papanicolaou GA. Hematologic safety profile of linezolid in the early periengraftment period after allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2009;15:1337-1341. Epub 2009 Jul 26.
- Amigues I, Cohen N, Chung D, Seo SK, Plescia C, Jakubowski A, Barker J, Papanicolaou GA. Hepatic safety of voriconazole after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2010;16:46-52. Epub 2009 Oct 9.
- Taur Y, Cohen N, Dubnow S, Paskovaty A, Seo SK. Effect of antifungal therapy timing on mortality in cancer patients with candidemia. Antimicrob Agents Chemother 2010;54:184-190. Epub 2009 Nov 2.
- Mihu C, Paskovaty A, Seo SK. Antimicrobial stewardship considerations for cancer centers. In: Safdar A (ed). Principles and Practice of Cancer Infectious Diseases. 1st ed. Totowa, NJ: Humana Press;2011:491-498.
- Kamboj M, Chung D, Seo SK, Pamer EG, Sepkowitz KA, Jakubowski AA, Papanicolaou G. The changing epidemiology of vancomycin-resistant Enterococcus (VRE) bacteremia in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Biol Blood Marrow Transplant 2010;16:1576-1581. Epub 2010 May 26.
- Kamboj M, Cohen N, Gilhuley K, Babady E, Seo SK, Sepkowitz KA. Emergence of daptomycin-resistant VRE: experience of a single institution. Infect Control Hosp Epidemiol 2011;32:391-394.
- Cosgrove SE, Seo SK, Bolon MK, Sepkowitz KA, Climo MW, Diekema DJ, Speck K, Gunaseelan V, Noskin GA, Herwaldt LA, Wong E, Perl TM. CDC Epicenter Program. Evaluation of post-prescription review and feedback as a method of promoting rational antimicrobial use: a multicenter intervention. Infect Control Hosp Epidemiol 2012;33:374-380.
- Juthani-Mehta M, Seo SK, Bernstein P, Eagan J, Sohn S, Sepkowitz KA, Zuccotti G. Financial impact of coagulase-negative staphylococcal (CoNS) bacteremia at a cancer hospital. Epidemiol 4:147. doi:10.4172/2161-1165.1000147. Epub 2014 Jan 29.
- Seo SK, Xiao K, Jongwutiwes U, Huang YT, Chung D, Maloy M, Giralt S, Barker JN, Jakubowski AA, Papanicolaou GA. Impact of peri-transplant vancomycin and fluoroquinolone administration on rates of bacteremia in allogeneic hematopoietic stem cell transplant (HSCT) recipients: a 12-year single institution study. J Infect 2014;69:341-351.doi:10.1016/j.jinf.2014.06.004. Epub 2014 Jun 12.
- Parameswaran L, Taur Y, Shah MK, Traina TA, Seo SK. Tolerability of chemotherapy in HIV-infected women with breast cancer: are there prognostic implications? AIDS Patient Care STDS 2014;28:358-364. doi:10.1089/apc.2013.0370. Epub 2014 May 19.
- Paskovaty A, Lucarelli C, Patel P, Ryan M, Seyboth B, Thackray J, Pozotrigo M, Cohen N, Seo SK. Experience of one antimicrobial stewardship program’s collaborative approach to managing a critical pentamidine shortage. Amer J Health Syst Pharm 2014;71:2014-2018.
- Otto C, Shuptar S, Milord P, Essick C, Nevrekar R, Granovsky S, Seo SK, Babady NE, Martin S, Tang YW, Pessin M. Reducing unnecessary and duplicating ordering for ova & parasites and Clostridium difficile PCR using an alert at the time of request in the order management system. J Clin Microbiol 2015;53:2745-2748. doi:10.1128/JCM.00968-15.
- Cohen N and Seo SK. Role of antimicrobial prophylaxis during treatment of adults with acute leukemia. Int J Hematol Oncol 2015;4:77-86. doi:10.2217/ijh.15.7.
- Ludwig E, Cohen N, Papanicolaou GA, Seo SK. Screening and prevention of hepatitis B virus reactivation during chemotherapy. Oncology (Williston Park) 2015;29:937, 940-943.
- Paskovaty A, Pastores SM, Gedrimaite Z, Kostelecky N, Riedel ER, Seo SK. Antimicrobial de-escalation in septic cancer patients: is it safe to back down? Intensive Care Med 2015;41:11:2022-2023. doi: 10.1007/s00134-015-4016-6. Epub 2015 Aug 22.
- Barlam TF, Cosgrove SE, Abbo LM, MacDongall C, Schuetz AN, Septimus EJ, Srinivasan A, Dellit TH, Falck-Ytter YT, Fishman NO, Hamilton CW, Jenkins TC, Lipsett PA, Malani PN, May LS, Moran GJ, Neuhauser MM, Newland JG, Ohl CA, Samore MH, Seo SK, Trivedi KK. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62:e51-e77. doi: 10.1093/cid/ciw118. Epub 2016 Apr 13.
- Satlin MJ, Cohen N, Ma KC, Gedrimaite Z, Soave R, Askin G, Chen L, Kreiswirth BN, Walsh TJ, Seo SK. Bacteremia due to carbapenem-resistant Enterobacteriaceae in neutropenic patients with hematologic malignancies. J Infect 2016;73:336-345. doi: 10.1016/j.jinf.2016.07.002. Epub 2016 Jul 9.
- Seo SK, Lo K, Abbo LM. Current state of antimicrobial stewardship at solid organ and hematopoietic cell transplant centers in the US. Infect Control Hosp Epidemiol 2016;37:1195-1200. doi: 10.1017/ice.2016.149. Epub 2016 Jul 26.
- Hamdy RF, Zaoutis TE, Seo SK. Antifungal stewardship considerations for adults and pediatrics. Virulence 2016 Sep 2:1-15. [Epub ahead of print]
- Djurkovic S, Kim M, Zhang H, Paskovaty A, Halpern N, Seo SK, Pastores S. Prevalence and outcome of bloodstream infections in cancer patients admitted to the intensive care unit. (43rd annual meeting of IDSA, October 6-9, 2005, San Francisco, CA)
- Paskovaty A, Kim M, Djurkovic S, Zhang H, Halpern NA, Pastores SM, Seo SK. Impact of empiric antimicrobial selection on hospital mortality of critically ill cancer patients with bloodstream infections. (35th annual meeting of the Society of Critical Care Medicine, January 7-11, 2006, San Francisco, CA)
- Taur Y, Cohen N, Dubnow S, Paskovaty A, Seo S. Effect of antifungal timing on mortality in cancer patients with candidemia. (47th annual meeting of ICAAC, September 17-20, 2007, Chicago, IL)
- Taur Y, Chung D, Parameswaran L, Lee YJ, Jakubowski A, Seo S, Papanicolaou G. Trends in early bloodstream infections in patients undergoing hematopoietic allogeneic stem cell transplantation. (49th annual meeting of IDSA, October 20-23, 2011, Boston, MA)
- Jongwutiwes U, Xiao K, Chung D, Chakraborty A, Giralt S, Jakubowski A, Seo SK, Papanicolaou G. Trends in rates and organisms of bacteremia after allogeneic stem cell transplantation during two different prophylactic strategies: a 12-year experience at Memorial Sloan-Kettering Cancer Center. (2013 BMT Tandem Meetings, February 13-17, 2013, Salt Lake City, UT)
- Palomino P, Cohen N, Gedrimaite Z, Riedel E, Paskovaty A, Chou A, Renaud T, Tang YW, NE Babady, Seo SK. Can the respiratory viral panel reduce antibiotic use in hospitalized pediatric patients with cancer? (54th annual meeting of ICAAC, September 5-9, 2014, Washington, DC)
- Satlin MJ, Cohen N, Ma KC, Gedrimaite Z, Walsh TJ, Seo SK. Prevalence, risk factors and outcomes of bacteremia due to carbapenem-resistant Enterobacteriaceae in neutropenic patients with hematologic malignancies. (IDWeek 2014, October 8-12, 2014, Philadelphia, PA)
- Ostrowsky B, Nori P, Munjal I, del Castillo M, Seo SK. Pooling NYC resources to educate fellows about antimicrobial stewardship and infection prevention and control (IDWeek 2015, October 7-11, 2015, San Diego, CA)
- Abbo L, Lo K, Seo SK. Antimicrobial stewardship programs in solid organ and hematopoietic stem cell transplant centers. (IDWeek 2015, October 7-11, 2015, San Diego, CA)
- Wiesenthal A, Lucca Bianchi A, Dave V, Sidlow R, Seo S, Korenstein D. Inpatient care at the end of life: a close look. (2015 Palliative Care in Oncology Symposium, October 9-10, 2015, Boston, MA)
- Yan SQ, Seyboth B, Kobos R, Cohen N, Seo SK. Voriconazole dosing in children younger than 3 years undergoing cancer chemotherapy or hematopoietic stem cell transplantation. (The American Society of Pediatric Hematology/Oncology’s 29th Annual Meeting, May 11-14, 2016, Minneapolis, MN)
- Paskovaty A, Babady EN, Tang YW, Kamboj M, Seo SK. Oritavancin susceptibility testing among vancomycin resistant Enterococcus faecium blood isolates. (ASM Microbe 2016, June 16-20, 2016, Boston, MA)
- Pettit N, Miceli M, Rivera C, Perissinotti A, delaCruz J, Gedrimaite Z, Han Z, Steinbeck J, Hsu M, Narayanan P, Pisano J, Seo S, Paskovaty A. Multicenter study of posaconazole delayed-release tablet serum level and association with hepatic and cardiac toxicity. (ASM Microbe 2016, June 16-20, 2016, Boston, MA)
- Otto C, Buonocore D, Cohen N, Leduc C, Seo S, Babady E. Comparison of fungal culture to surgical pathology exam in the detection of dimorphic fungi and the impact on treatment and outcomes: a 25 year retrospective review at a tertiary cancer center. (51st annual meeting of the Academy of Clinical Laboratory Physicians and Scientists, June 2-4, 2016, Birmingham, AL)
- Romero FA, Seo SK, Taur Y, Sauter C, Park J, Hohl TM. Infections presenting 30 days after Chimeric Antigen Receptor (CAR) modified T-cells: a single-center experience. (IDWeek 2016, October 26-30, 2016, New Orleans, LA)
- Robilotti E, Cohen N, Kamboj M, Seo S. Antibiotic exposure after Clostridium difficile infection (CDI) diagnosis in pediatric oncology patients. (IDWeek 2016, October 26-30, 2016, New Orleans, LA)
February 2016: MSK’s AMP was awarded a grant from the United Hospital Fund for an outpatient antibiotic stewardship PI project. MSK is one of eight New York City hospitals and health systems to be participating in this initiative.
April 2016: The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America released updated guidelines for implementing antimicrobial stewardship programs.
May 2016: The Infectious Disease Society of New York (IDSNY) Pre-Meeting workshop on Antimicrobial Stewardship (AS) and Infection Control for regional ID fellows was held at Lenox Hill Hospital. MSK clinical pharmacist Alla Paskovaty was an AS panelist. MSK ID fellows Esther Arguello, Alexandra Franco, and Andres Romero contributed case vignettes.
June 2016: Alla Paskovaty gave an oral presentation entitled “Multicenter study of posaconazole delayed-release table serum level and association with hepatic and cardiac toxicity” at the ASM Microbe 2016 meeting held in Boston, June 16-20, 2016. The University of Chicago, Mayo Clinic, and the University of Michigan were the other collaborating centers for this project.
July 2016: Marco Scipione joined the MSK’s Antibiotic Management Program this month. After infectious diseases (ID) pharmacy training at the Brooklyn Hospital Center, Dr. Scipione worked as an ID clinical pharmacy specialist at New York University, where he was active in antimicrobial stewardship and teaching pharmacy residents, medical house officers, and ID fellows.
October 2016: Susan Seo gave a talk entitled “MDRO Bacteremias in Oncology: Real and Present Danger” as part of Symposium 113 Navigating Antimicrobial Resistance in Oncology and Transplantation for IDWeek 2016 held in New Orleans, LA.