Skip to main content Accessibility help
×
×
Home

The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities

  • Erika M. C. D’Agata (a1), Curt C. Lindberg (a2), Claire M. Lindberg (a3), Gemma Downham (a4), Brandi Esposito (a4), Douglas Shemin (a5) and Sophia Rosen (a6)...
Abstract
Background

Antimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%–35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed.

Objective

To quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.

Study design and setting

An interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period.

Results

Implementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met.

Conclusions

Within 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.

Copyright
Corresponding author
Author for correspondence: Erika M.C. D’Agata MD, MPH, Division of Infectious Diseases, Brown University, 593 Eddy Street, Aldrich 720, Providence, RI. E-mail: edagata@lifespan.org
Footnotes
Hide All

Cite this article: D’Agata EMC, et al. (2018). The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities. Infection Control & Hospital Epidemiology 2018, 39, 1400–1405. doi: 10.1017/ice.2018.237

Footnotes
References
Hide All
1. Karanika, S, Paudel, S, Grigoras, C, Kalbasi, A, Mylonakis, E. Systematic review and meta-analysis of clinical and economic outcomes from the implementation of hospital-based antimicrobial stewardship programs. Antimicrob Agents Chemother. 2016;60:48404852.
2. Tamma, PD, Avdic, E, Li, DX, Dzintars, K, Cosgrove, SE. association of adverse events with antibiotic use in hospitalized patients. JAMA Intern Med 2017;177:13081315.
3. Zacharioudakis, IM, Zervou, FN, Ziakas, PD, Rice, LB, Mylonakis, E. Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance. Am J Kidney Dis 2015;65:8897.
4. Zacharioudakis, IM, Zervou, FN, Ziakas, PD, Mylonakis, E. Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients. J Am Soc Nephrol 2014;25:21312141.
5. Song, J., Park, HK, Kang, HK, Lee, J. Proposed risk factors for infection with multidrug-resistant pathogens in hemodialysis patients hospitalized with pneumonia. BMC Infect Dis 2017;17:681690.
6. Marston, HD, Dixon, DM, Knisely, JM, Palmore, TN, Fauci, AS. Antimicrobial resistance. JAMA 2016;316:11931204.
7. Core elements of hospital antibiotic stewardship programs. Centers for Disease Control and Prevention website. https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Updated 2017. Accessed March 21, 2018.
8. Baur, D, Gladstone, BP, Burkert, F, et al. Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis 2017;17:9901001.
9. Joint Commission Perspectives, July 2016, vol. 36, issue 7. Oakbrook Terrace, IL: The Joint Commission; 2016.
10. Snyder, GM, Patel, PR, Kallen, AJ, Strom, JA, Tucker, JK, D’Agata, EM. Antimicrobial use in outpatient hemodialysis units. Infect Control Hosp Epidemiol. 2013;34:349357.
11. Hui, K, Nalder, M, Buising, K, et al. Patterns of use and appropriateness of antibiotics prescribed to patients receiving haemodilaysis: an observational study. BMC Nephrol 2017;18:156.
12. Snyder, G, Patel, PR, Kallen, AJ, Strom, JA, Tucker, JK, D’Agata, EMC. Factors associated with the receipt of antimicrobials among chronic hemodialysis patients. Am J Infect Control 2016;44:12691274.
13. Central line-associated bloodstream infection (CLABSI) event. Centers for Disease Control and Prevention website. http://www.cdc.gov/nhsn/TOC_PSCManual.html. Published 2012. Accessed August 25, 2018.
14. Clinical practice guidelines for vascular access. Am J Kidney Dis 006 2;48 Suppl 1:S176S247.
15. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006;48 Suppl 1:S248S273.
16. 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;9:643654.
17. 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.
18. 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;41:13731406.
19. 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.
20. 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;48:149171.
21. 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;11:79109.
22. Anderson, DJ, Sexton, DJ.Overview of control measures to prevent surgical site infection. In: Harris A, ed. UpToDate. Waltham, MA: Wolters Kluwer Health; 2012.
23. 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:e103e120.
24. 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;50:625663.
25. 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;268:15781580.
26. 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;18:422427.
27. Pascale, RS. The power of positive deviance: how unlikely innovators solve the world’s toughest problems. Boston: Harvard Business School Press. 2010.
28. Downham, G, Jones, E, Peterson, P, et al. Reducing bloodstream infections in an outpatient hemodialysis center—New Jersey, 20082011. Morb Mort Weekly Rep 2012;61:169173.
29. Lindberg, C, Downham, G, Buscell, P, Jones, E, Peterson, P, Krebs, V. Embracing collaboration: a novel strategy for reducing blood stream infections in outpatient dialysis centers. Am J Infect Control 2013:41:513519.
30. Schweizer, ML, Braun, BI, Milstone, AM. Research methods in healthcare epidemiology and antimicrobial stewardship-quasi-experimental designs. Infect Control Hosp Epidemiol 2016;37:11351140.
31. Wagner, AK, Soumerai, SB, Zhang, F, Ross-Degnan, D. Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 2012;27:299330.
32. Schweizer, ML, Furuno, JP, Harris, AD et al. Comparative effectiveness of nafcillin versus vancomycin in methicillin-susceptible Staphylococcus aureus bacteremia. BMC Infect Dis 2011;11:279286.
33. Stryjewski, ME, Szczech, LA, Benjamin, DK, 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;44:190196.
34. Chan, KE, Warren, HS, Thadhani, RI, et al. Prevalence and outcomes of antimicrobial treatment for Staphylococcus aureus bacteremia in outpatients with ESRD. J Am Soc Nephrol 2012;23:15511559.
35. Saely, S, Kaye, KS, Fairfax, MR, Chopra, T, Pogue, JM. Investigating the impact of the definition of previous antibiotic exposure related to isolation of extended spectrum β-lactamase–producing Klebsiella pneumoniae . Am J Infect Control 2011;39:390395.
36. Cunha, CB, D’Agata, EMC. Antimicrobial stewardship in out-patient dialysis units. Curr Opin Nephrol Hypertens 2016;25:551555.
37. Dellit, TH, Owens, RC, McGowan, JE, 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;44:159177.
38. D’Agata, EMC. Addressing the problem of multidrug-resistant organisms in dialysis facilities. Clin J Amer Soc Nephrol 2018 (in press).
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed