Advertisement

Factors associated with the receipt of antimicrobials among chronic hemodialysis patients

      Highlights

      • All parenteral antimicrobials administered to patients requiring chronic hemodialysis in 2 outpatient hemodialysis units over a 12-month period were quantified and assessed for appropriateness based on published guidelines.
      • A third of patients received at least 1 dose of antimicrobials, and among these, more than half received at least 1 inappropriately indicated dose.
      • Patients with a tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving hemodialysis during daytime shifts were more likely to receive antimicrobials.
      • Patients with a tunneled catheter access, receiving dialysis in unit B, and with a longer duration of hemodialysis prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose.
      • Antimicrobial stewardship efforts in outpatient hemodialysis may focus on minimizing tunneled catheter use, incorporate prior history of multidrug-resistant organisms, and will likely require unit-specific practices.

      Background

      Antimicrobial use is common among patients receiving chronic hemodialysis (CHD) and may represent an important antimicrobial stewardship opportunity. The objective of this study is to characterize CHD patients at increased risk of receiving antimicrobials, including not indicated antimicrobials.

      Methods

      We conducted a prospective cohort study over a 12-month period among patients receiving CHD in 2 outpatient dialysis units. Each parenteral antimicrobial dose administered was characterized as indicated or not indicated based on national guidelines. Patient factors associated with receipt of antimicrobials and receipt of ≥1 inappropriate antimicrobial dose were analyzed.

      Results

      A total of 89 of 278 CHD patients (32%) received ≥1 antimicrobial doses and 52 (58%) received ≥1 inappropriately indicated dose. Patients with tunneled catheter access, a history of colonization or infection with a multidrug-resistant organism, and receiving CHD sessions during daytime shifts were more likely to receive antimicrobials (odds ratio [OR], 5.16; 95% confidence interval [CI], 2.72-9.80; OR, 5.43; 95% CI, 1.84-16.06; OR, 4.59; 95% CI, 1.20-17.52, respectively). Patients with tunneled catheter access, receiving CHD at dialysis unit B, and with a longer duration of CHD prior to enrollment were at higher risk of receiving an inappropriately indicated antimicrobial dose (incidence rate ratio, 2.23; 95% CI, 1.16-4.29; incidence rate ratio, 2.67; 95% CI, 1.34-5.35; incidence rate ratio, 1.11; 95% CI, 1.01-1.23, respectively).

      Conclusions

      This study of all types of antimicrobials administered in 2 outpatient dialysis units identified several important factors to consider when developing antimicrobial stewardship programs in this health care setting.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Snyder G.M.
        • D'Agata E.M.
        Novel antimicrobial-resistant bacteria among patients requiring chronic hemodialysis.
        Curr Opin Nephrol Hypertens. 2012; 21: 211-215
        • Pop-Vicas A.
        • Strom J.
        • Stanley K.
        • D'Agata E.M.
        Multidrug-resistant gram-negative bacteria among patients who require chronic hemodialysis.
        Clin J Am Soc Nephrol. 2008; 3: 752-758
        • U.S. Renal Data System
        USRDS 2010 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)2010
        • Pakyz A.L.
        • Dwyer L.L.
        Prevalence of antimicrobial use among United States nursing home residents: results from a national survey.
        Infect Control Hosp Epidemiol. 2010; 31: 661-662
        • O'Fallon E.
        • Schreiber R.
        • Kandel R.
        • D'Agata E.M.
        Multidrug-resistant gram-negative bacteria at a long-term care facility: assessment of residents, healthcare workers, and inanimate surfaces.
        Infect Control Hosp Epidemiol. 2009; 30: 1172-1179
        • Snyder G.M.
        • Patel P.R.
        • Kallen A.J.
        • Strom J.A.
        • Tucker J.K.
        • D'Agata E.M.
        Antimicrobial use in outpatient hemodialysis units.
        Infect Control Hosp Epidemiol. 2013; 34: 349-357
        • Green K.
        • Schulman G.
        • Haas D.W.
        • Schaffner W.
        • D'Agata E.M.
        Vancomycin prescribing practices in hospitalized chronic hemodialysis patients.
        Am J Kidney Dis. 2000; 35: 64-68
        • Zvonar R.
        • Natarajan S.
        • Edwards C.
        • Roth V.
        Assessment of vancomycin use in chronic haemodialysis patients: room for improvement.
        Nephrol Dial Transplant. 2008; 23: 3690-3695
      1. Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC).
        MMWR Recomm Rep. 1995; 44: 1-13
        • Vascular Access 2006 Work Group
        Clinical practice guidelines for vascular access.
        Am J Kidney Dis. 2006; 48: S176-247
        • Vascular Access Work Group
        Clinical practice guidelines for vascular access.
        Am J Kidney Dis. 2006; 48: S248-73
        • Anderson D.J.
        • Sexton D.J.
        Harris A. Overview of control measures to prevent surgical site infection. UpToDate, Waltham (MA)2012
        • Dellinger E.P.
        • Gross P.A.
        • Barrett T.L.
        • Krause P.J.
        • Martone W.J.
        • McGowan Jr, J.E.
        • et al.
        Quality standard for antimicrobial prophylaxis in surgical procedures. Infectious Diseases Society of America.
        Clin Infect Dis. 1994; 18: 422-427
        • High K.P.
        • Bradley S.F.
        • Gravenstein S.
        • Mehr D.R.
        • Quagliarello V.J.
        • Richards C.
        • 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: 149-171
        • Mackowiak P.A.
        • Wasserman S.S.
        • Levine M.M.
        A critical appraisal of 98.6 degrees F, the upper limit of the normal body temperature, and other legacies of Carl Reinhold August Wunderlich.
        JAMA. 1992; 268: 1578-1580
        • Mandell L.A.
        • Wunderink R.G.
        • Anzueto A.
        • Bartlett J.G.
        • Campbell G.D.
        • Dean N.C.
        • 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: S27-72
        • Nicolle L.E.
        • Bradley S.
        • Colgan R.
        • Rice J.C.
        • Schaeffer A.
        • Hooton T.M.
        Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults.
        Clin Infect Dis. 2005; 40: 643-654
        • Solomkin J.S.
        • Mazuski J.E.
        • Bradley J.S.
        • Rodvold K.A.
        • Goldstein E.J.
        • Baron E.J.
        • 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: 79-109
        • Stevens D.L.
        • Bisno A.L.
        • Chambers H.F.
        • Everett E.D.
        • Dellinger P.
        • Goldstein E.J.
        • et al.
        Practice guidelines for the diagnosis and management of skin and soft-tissue infections.
        Clin Infect Dis. 2005; 41: 1373-1406
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Beddhu S.
        • Zeidel M.L.
        • Saul M.
        • Seddon P.
        • Samore M.H.
        • Stoddard G.J.
        • et al.
        The effects of comorbid conditions on the outcomes of patients undergoing peritoneal dialysis.
        Am J Med. 2002; 112: 696-701
        • Centers for Disease Control and Prevention
        Central line-associated bloodstream infection (CLABSI) event.
        2012 (Available from) (Accessed May 2, 2016)
        • Klevens R.M.
        • Edwards J.R.
        • Andrus M.L.
        • Peterson K.D.
        • Dudeck M.A.
        • Horan T.C.
        Dialysis surveillance report: National Healthcare Safety Network (NHSN)-data summary for 2006.
        Semin Dial. 2008; 21: 24-28
        • Galoisy-Guibal L.
        • Soubirou J.L.
        • Desjeux G.
        • Dusseau J.Y.
        • Eve O.
        • Escarment J.
        • et al.
        Screening for multidrug-resistant bacteria as a predictive test for subsequent onset of nosocomial infection.
        Infect Control Hosp Epidemiol. 2006; 27: 1233-1241
        • Pacio G.A.
        • Visintainer P.
        • Maguire G.
        • Wormser G.P.
        • Raffalli J.
        • Montecalvo M.A.
        Natural history of colonization with vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and resistant gram-negative bacilli among long-term-care facility residents.
        Infect Control Hosp Epidemiol. 2003; 24: 246-250
        • Rayner H.C.
        • Besarab A.
        • Brown W.W.
        • Disney A.
        • Saito A.
        • Pisoni R.L.
        Vascular access results from the Dialysis Outcomes and Practice Patterns Study (DOPPS): performance against Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines.
        Am J Kidney Dis. 2004; 44: 22-26
        • Allon M.
        • Daugirdas J.
        • Depner T.A.
        • Greene T.
        • Ornt D.
        • Schwab S.J.
        Effect of change in vascular access on patient mortality in hemodialysis patients.
        Am J Kidney Dis. 2006; 47: 469-477
        • Lacson Jr, E.
        • Wang W.
        • Lazarus J.M.
        • Hakim R.M.
        Change in vascular access and mortality in maintenance hemodialysis patients.
        Am J Kidney Dis. 2009; 54: 912-921
        • Asif A.
        • Cherla G.
        • Merrill D.
        • Cipleu C.D.
        • Briones P.
        • Pennell P.
        Conversion of tunneled hemodialysis catheter-consigned patients to arteriovenous fistula.
        Kidney Int. 2005; 67: 2399-2406
        • Bradbury B.D.
        • Chen F.
        • Furniss A.
        • Pisoni R.L.
        • Keen M.
        • Mapes D.
        • et al.
        Conversion of vascular access type among incident hemodialysis patients: description and association with mortality.
        Am J Kidney Dis. 2009; 53: 804-814
        • Dellit T.H.
        • Owens R.C.
        • McGowan Jr, J.E.
        • Gerding D.N.
        • Weinstein R.A.
        • Burke J.P.
        • 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: 159-177
        • Schwartz D.N.
        • Wu U.S.
        • Lyles R.D.
        • Xiang Y.
        • Kieszkowski P.
        • Hota B.
        • et al.
        Lost in translation? Reliability of assessing inpatient antimicrobial appropriateness with use of computerized case vignettes.
        Infect Control Hosp Epidemiol. 2009; 30: 163-171