1404
Erika M.C. D’Agata et al
Table 3. Comparison of Mean Rates of Antimicrobial Doses per 100 Patient Months During the Preintervention and Intervention Periods Antimicrobial
Preintervention Period, Mean Rate per 100 Patient Months (SD)
Broad-spectrum cephalosporinsa
Gentamicin Cefazolin
0.30 (0.6)
1.96 (2.4) 2.77 (3.8)
Note. SD, standard deviation. aBroad-spectrum cephalosporins: cefepime, ceftazidime, ceftriaxone.
cefazolin-susceptible pathogen. Avoiding broad-spectrum cepha- losporins diminishes the likelihood of the emergence and spread of multidrug-resistant gram-negative bacteria. These pathogens include extended-spectrum β-lactamase–producing Enter- obacteriaceae, which are frequent among the dialysis popula- tion.35 Other important recommendations provided by the antimicrobial stewardship program included discontinuing anti- microbials when criteria, based on national guidelines, for pre- sumed infections were not met and when dual antimicrobial therapy was not indicated. The Centers for Medicare and Medicaid Services and the Joint Commission now require antimicrobial stewardship programs in hospitals and nursing care centers. Numerous resources are available to guide the implementation of these programs. Although these resources do not specifically target the main- tenance hemodialysis population, many can be adapted to the out-patient dialysis units.36 The core elements of antimicrobial stewardship programs, which were also included in this study, are the following: (1) leadership commitment to support required personnel and financial resources, (2) identification of the leader of the antimicrobial stewardship program, who should have drug expertise and will lead the effort, including monitoring adherence to the program and its outcomes, (3) implementation of policies that support optimal prescribing of antimicrobials, (4) method for tracking the program’s effectiveness, (5) provision of feedback pertaining to rates of antimicrobial use and other outcomes to all relevant staff, and (6) educational efforts focusing on the negative impacts of antimicrobial use and optimization of antimicrobial prescribing.7 This study has several limitations. First, although 6 facilities
were enrolled, these results may not be generalizable to other dialysis facilities. Second, while nurse managers, identified as the unit-based program leaders, were provided with educational resources that focused on optimizing antimicrobial prescribing, recommendations were also provided by an infectious disease physician. Because an infectious disease physician may not be available to all future antimicrobial stewardship programs in dialysis facilities, further training in drug expertise should be provided to these leaders. Numerous resources are publicly available from the Agency of Healthcare Research and Quality, Centers for Disease Control and Prevention, the Society of Healthcare Epidemiology and the Infectious Disease Society of America.7,37 These resources include workshops, guidelines, and implementation and audit tools. Third, although calls were established to review the indications for antimicrobial prescribing in the previous month, using a more timely approach, such as checklist prior to administering antimicrobials, may have increased the efficacy of the program. Lastly, we did not find significant differences in negative outcomes including rates of hospitalization and all types of BSI. We did detect a trend toward
an increase in MRSA BSI during the intervention period, although there was no significant decrease in vancomyin use. Future programs need to monitor for potential negative outcomes. The efficacy of antimicrobial stewardship programs in
improving antimicrobial prescribing patters and reducing unne- cessary exposure have been widely documented in the hospital setting. This study provides data to support the efficacy of these programs in dialysis facilities. Improving antimicrobial prescrib- ing practices in outpatient dialysis facilities is critical for ensuring optimal infection management, reducing adverse drug events, and curtailing the ongoing emergence and spread of MDROs.36,38 Dialysis facilities should consider implementing antimicrobial stewardship programs toward the ultimate goal of improving the quality of life of maintenance hemodialysis patients.
Acknowledgments.
Financial support. This work was supported by the Agency of Healthcare Research and Quality (AHRQ grant no R18 HS021666 to E.M.C.D.) and the National Institute of Allergy and Infectious Diseases (NIAID grant no. K24 AI119158 to E.M.C.D.). The funding agencies did not have any role in the study design, collection, analysis and interpretation of the data, writing the report or decision to submit the report for publication.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
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;60:4840–4852.
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;177:1308–1315.
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;65:88–97.
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;25:2131–2141.
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;17:681–690.
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https://www.cdc.gov/getsmart/ healthcare/implementation/
core-elements.html. Updated 2017. Accessed March 21, 2018.
1.21 (1.7)
2.03 (1.38) 2.87 (4.06)
Intervention Period, Mean Rate per 100 Patient Months (SD)
P
Value .29
.90 .86
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