Infection Control & Hospital Epidemiology (2018), 39, 1400–1405 doi:10.1017/ice.2018.237


Original Article


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


Erika M. C. D’Agata MD, MPH1, Curt C. Lindberg DMan MHA2, Claire M. Lindberg PhD, RN3, Gemma Downham MPH4, Brandi Esposito RN4, Douglas Shemin MD5 and Sophia Rosen PhD6 1Division of Infectious Diseases, Rhode Island Hospital, Brown University, Providence, Rhode Island, 2Billings Clinic, Billings, Montana, 3Department of Nursing,


The College of New Jersey, Ewing Township, New Jersey, 4AtlantiCare Regional Medical Center, Pomona, New Jersey, 5Division of Nephrology, Rhode Island Hospital, Brown University, Providence, Rhode Island and 6Fresenius Medical Care North America, Burlington, Massachusetts


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.


(Received 2 July 2018; accepted 21 August 2018; electronically published September 26, 2018)


Although antimicrobials substantially improve rates of patient morbidity and mortality, numerous negative downstream con- sequences can occur, including the emergence and spread of multidrug-resistant organisms (MDROs), Clostridium difficile infections, drug–drug interactions, and adverse drug events.1,2 MDROs are particularly relevant to the population of main- tenance hemodialysis patients because rates of colonization and infection in this population are among the highest among all patient populations.3–5 Furthermore, MDROs cause ~2 million infections and 23,000 deaths per year, with an annual excess cost to the medical system of $20 billion.6 The ongoing spread of MDROs and emergence of novel antimicrobial resistance profiles further emphasizes their significant public health threat. It has been estimated that 20%–50% of prescribed anti- microbials are not appropriate or not necessary.7 The


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


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


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


nistered are unnecessary.10,11 Although antimicrobial stewardship programs have been established for hospital and long-term care settings,7 programs targeting the unique aspects of outpatient dialysis facilities, where patients receive care at regular intervals, have not been developed. In this study, a multifaceted anti- microbial stewardship program was developed and implemented in 6 outpatient dialysis facilities, and its efficacy in decreasing antimicrobial use was evaluated.


implementation of antimicrobial stewardship programs are an effective strategy toward decreasing unnecessary antimicrobial exposure and improving antimicrobial prescribing patterns. In the hospital and long-term care settings, antimicrobial steward- ship programs have been shown to reduce antimicrobial pre- scribing by ≥20% and to reduce infections caused by MDROs and Clostridium difficile, adverse drug events and costs.1,8 In response to these data, the Centers for Medicare and Medicaid Services and the Joint Commission require antimicrobial stew- ardship programs in hospitals and nursing care centers, and similar requirements are under development for ambulatory care settings.9 In dialysis facilities, ~30%–35% of antimicrobial doses admi-


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