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Antimicrobial Use in Outpatient Hemodialysis Units

  • Graham M. Snyder (a1), Priti R. Patel (a2), Alexander J. Kallen (a2), James A. Strom (a3), J. Kevin Tucker (a4) and Erika M. C. D'Agata (a1)...
Abstract
Objective.

To quantify and characterize overall antimicrobial use, including appropriateness of indication, among patients receiving chronic hemodialysis.

Design.

Retrospective and prospective observational study.

Setting.

Two outpatient hemodialysis units.

Patients.

All patients receiving chronic hemodialysis.

Methods.

The rate of parenteral antimicrobial use (number of doses per 100 patient-months) was calculated retrospectively from September 2008 through July 2011. Indication and appropriateness of antimicrobial doses were characterized prospectively from August 2010 through July 2011. Inappropriate administration was defined as occasions when criteria for infection based on national guidelines were not met, failure to choose a more narrow-spectrum antimicrobial on the basis of culture data, or occasions when indications for surgical prophylaxis were not met.

Results.

Over the 35-month retrospective study period, the rate of parenteral antimicrobial use was 32.9 doses per 100 patient-months. Vancomycin was the most commonly prescribed antimicrobial, followed by cefazolin and third- or fourth-generation cephalosporins. Over the 12-month prospective study, 1,003 antimicrobial doses were prescribed. Among the 926 (92.3%) doses for which an indication for administration was available, 276 (29.8%) were classified as inappropriate. Of these, a total of 146 (52.9%) did not meet criteria for infection, 74 (26.8%) represented failure to choose a more narrow-spectrum antimicrobial, and 56 (20.3%) did not meet criteria for surgical prophylaxis. The most common inappropriately prescribed antimicrobials were vancomycin and third- or fourth- generation cephalosporins.

Conclusions.

Parenteral antimicrobial use was extensive, and as much as one-third was categorized as inappropriate. The findings of this study provide novel information toward minimizing inappropriate antimicrobial use.

Copyright
Corresponding author
Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 330 Brookline Avenue, Mailstop SL-435, Boston, MA 02215 (gsnyder@bidmc.harvard.edu)
References
Hide All
1.U.S. Renal Data System. USRDS 2009 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2009.
2.Li Y, Friedman JY, O'Neal BF, et al.Outcomes of Staphylococcus aureus infection in hemodialysis-dependent patients. Clin J Am Soc Nephrol 2009;4(2):428434.
3.Engemann JJ, Friedman JY, Reed SD, et al.Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis. Infect Control Hosp Epidemiol 2005;26(6):534539.
4.Schwaber MJ, Navon-Venezia S, Kaye KS, Ben-Ami R, Schwartz D, Carmeli Y. Clinical and economic impact of bacteremia with extended-spectrum-β-lactamase-producing Enterobacteriaceae. Antimicrob Agents Chemother 2006;50(4):12571262.
5.Cosgrove SE. The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs. Clin Infect Dis 2006;42(suppl 2):S82S89.
6.Centers for Disease Control and Prevention. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients—United States, 2005. MMWR Morb Mortal Wkly Rep 2007;56(9):197199.
7.Snyder GM, D'Agata EM. Novel antimicrobial-resistant bacteria among patients requiring chronic hemodialysis. Curr Opin Nephrol Hypertens 2012;21(2):211215.
8.Pop-Vicas A, Strom J, Stanley K, D'Agata EM. Multidrug-resistant gram-negative bacteria among patients who require chronic hemodialysis. Clin J Am Soc Nephrol 2008;3(3):752758.
9.Lautenbach E, Patel JB, Bilker WB, Edelstein PH, Fishman NO. Extended-spectrum β-lactamase–producing Escherichia coli and Klebsiella pneumoniae: risk factors for infection and impact of resistance on outcomes. Clin Infect Dis 2001;32(8):11621171.
10.Dellit TH, Owens RC, McGowan JE Jr, et al.Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44(2):159177.
11.Klevens RM, Edwards JR, Andrus ML, Peterson KD, Dudeck MA, Horan TC. Dialysis Surveillance Report: National Health-care Safety Network (NHSN)—data summary for 2006. Semin Dial 2008;21(1):2428.
12.George A, Tokars JI, Clutterbuck EJ, Bamford KB, Pusey C, Holmes AH. Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study. BMJ 2006;332:1435.
13.Green K, Schulman G, Haas DW, Schaffner W, D'Agata EM. Vancomycin prescribing practices in hospitalized chronic hemodialysis patients. Am J Kidney Dis 2000;35(1):6468.
14.Zvonar R, Natarajan S, Edwards C, Roth V. Assessment of vancomycin use in chronic haemodialysis patients: room for improvement. Nephrol Dial Transplant 2008;23(11):36903695.
15. Centers for Disease Control and Prevention. Central line–associated bloodstream infection (CLABSI) event. 2012; http://www.cdc.gov/nhsn/TOC_PSCManual.html. Accessed May 8, 2012.
16.Vascular Access 2006 Working Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48(suppl 1):S176S273.
17.Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40(5):643654.
18.Mandell LA, Wunderink RG, Anzueto A, et al.Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(suppl 2):S27S72.
19.Stevens DL, Bisno AL, Chambers HF, et al.Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41(10):13731406.
20.Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1995;44(RR-12): 113.
21.High KP, Bradley SF, Gravenstein S, et al.Clinical practice guideline for the evaluation of fever and infection in older adult residents of long-term care facilities: 2008 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;48(2): 149171.
22.Solomkin JS, Mazuski JE, Bradley JS, et al.Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010;11(1):79109.
23.Anderson DJ, Sexton DJ. Overview of control measures to prevent surgical site infection. In: Harris A, ed. UpToDate, http://www.uptodate.com/contents/overview-of-control-measures-to-prevent-surgical-site-infection#H1. Published December 2012.
24.Baddour LM, Wilson WR, Bayer AS, et al.Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation 2005;111(23): e394e434.
25. Centers for Disease Control and Prevention. NHSN Dialysis Event Protocol. 2012; http://www.cdc.gov/nhsn/psc_da_de.html. Accessed July 10, 2012.
26.Gupta K, Hooton TM, Naber KG, et al.International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103e120.
27.Hooton TM, Bradley SF, Cardenas DD, et al.Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50(5):625663.
28.Mackowiak PA, Wasserman SS, Levine MM. A critical appraisal of 98.6°F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich. JAMA 1992;268(12):15781580.
29.Dellinger EP, Gross PA, Barrett TL, et al.Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America. Clin Infect Dis 1994;18(3):422427.
30.Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373383.
31.Beddhu S, Zeidel ML, Saul M, et al.The effects of comorbid conditions on the outcomes of patients undergoing peritoneal dialysis. Am J Med 2002;112(9):696701.
32.Schweizer ML, Furuno JP, Harris AD, et al.Comparative effectiveness of nafcillin or cefazolin versus vancomycin in methicillin-susceptible Staphylococcus aureus bacteremia. BMC Infect Dis 2011;11:279.
33.Stryjewski ME, Szczech LA, Benjamin DK Jr, et al.Use of vancomycin or first-generation cephalosporins for the treatment of ‘hemodialysis-dependent patients with methicillin-susceptible Staphylococcus aureus bacteremia. Clin Infect Dis 2007;44(2): 190196.
34.Salman L, Asif A. Antibiotic prophylaxis: is it needed for dialysis access procedures? Semin Dial 2009;22(3):297299.
35.Lu PL, Tsai JC, Chiu YW, et al.MethicOlin-resistant Staphylococcus aureus carriage, infection and transmission in dialysis patients, healthcare workers and their family members. Nephrol Dial Transplant 2008;23(5):16591665.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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