In the Journals

‘Significant opportunity’ for antimicrobial stewardship in hemodialysis facilities

An assessment of hemodialysis facilities in Philadelphia County revealed that almost 60% of new outpatient intravenous antimicrobial starts last year were inappropriate, researchers reported.

“In the sphere of antimicrobial stewardship efforts, hemodialysis facilities have not received a lot of attention, compared to other types of facilities. Hemodialysis facilities make up a large portion of the U.S. health care system and thus should be included in antimicrobial stewardship efforts,” Phillip D. Hahn, MPH, CPH, a CDC/Council of State and Territorial Epidemiologists applied epidemiology fellow with the Philadelphia Department of Public Health, told Infectious Disease News.

“The main implications of this study are that a significant opportunity for antimicrobial stewardship may exist in the hemodialysis setting and that the use of national surveillance systems, such as the National Healthcare Safety Network (NHSN), can be extremely beneficial for replicability across public health departments, health networks and at the level of the facility, specifically when creating a metric that can be used to prioritize resources and efforts.”

The researchers conducted a period prevalence study of intravenous antimicrobial starts (IVASs) reported in 2018 to the NHSN by hemodialysis facilities located in Philadelphia County. The analysis included 54 of 55 hemodialysis facilities in the County. Each facility had a medium of 20.5 (interquartile range [IQR], 16-24) dialysis stations and treated a median of 71.5 patients (IQR, 49-88). During the study period, 960 IVASs were documented over 42,175 patient-months. Months were broken down by patient access type: 24,612 fistula, 10,517 graft, 7,015 central line and 31 other.

The aggregate IVAS rate was 2.28 per 100 patient months, Hahn and colleagues reported. They found that aggregate IVAS rates among patients receiving hemodialysis through a fistula or graft were lower compared with patients with a central line (P < .001). Moreover, the aggregate IVAS rate among patients with a fistula was significantly lower compared with patients with a graft (P = .006). According to the study, 65.6% of IVAS regimens included vancomycin and 63.5% of IVASs were new outpatient initiations, rather than a continuation from inpatient antimicrobial treatments.

Hahn and colleagues reported that 57.5% of the new outpatients IVASs were classified as inappropriate. Among patients with a fistula or graft access type, inappropriate IVAS aggregate rates were lower compared with patients with a central line (P < .0001), and no significant difference was found between patients with a fistula compared with patients with a graft (P = .86).

“A review of patients without a documented indication for an antimicrobial prescription should be conducted to validate the metric and understand how precisely it measures the burden of inappropriate intravenous antimicrobial prescribing in hemodialysis facilities,” Hahn said. “Additionally, regional differences in overall patterns of antimicrobial prescribing have been noted, so future studies may want to look at this in the hemodialysis setting, specifically related to inappropriate prescribing. Because we used NHSN data, it is possible for public health departments, dialysis companies, and quality improvement organizations across the country to replicate this analysis and evaluate the rate of inappropriate antimicrobial prescribing in hemodialysis facilities in their area.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.

An assessment of hemodialysis facilities in Philadelphia County revealed that almost 60% of new outpatient intravenous antimicrobial starts last year were inappropriate, researchers reported.

“In the sphere of antimicrobial stewardship efforts, hemodialysis facilities have not received a lot of attention, compared to other types of facilities. Hemodialysis facilities make up a large portion of the U.S. health care system and thus should be included in antimicrobial stewardship efforts,” Phillip D. Hahn, MPH, CPH, a CDC/Council of State and Territorial Epidemiologists applied epidemiology fellow with the Philadelphia Department of Public Health, told Infectious Disease News.

“The main implications of this study are that a significant opportunity for antimicrobial stewardship may exist in the hemodialysis setting and that the use of national surveillance systems, such as the National Healthcare Safety Network (NHSN), can be extremely beneficial for replicability across public health departments, health networks and at the level of the facility, specifically when creating a metric that can be used to prioritize resources and efforts.”

The researchers conducted a period prevalence study of intravenous antimicrobial starts (IVASs) reported in 2018 to the NHSN by hemodialysis facilities located in Philadelphia County. The analysis included 54 of 55 hemodialysis facilities in the County. Each facility had a medium of 20.5 (interquartile range [IQR], 16-24) dialysis stations and treated a median of 71.5 patients (IQR, 49-88). During the study period, 960 IVASs were documented over 42,175 patient-months. Months were broken down by patient access type: 24,612 fistula, 10,517 graft, 7,015 central line and 31 other.

The aggregate IVAS rate was 2.28 per 100 patient months, Hahn and colleagues reported. They found that aggregate IVAS rates among patients receiving hemodialysis through a fistula or graft were lower compared with patients with a central line (P < .001). Moreover, the aggregate IVAS rate among patients with a fistula was significantly lower compared with patients with a graft (P = .006). According to the study, 65.6% of IVAS regimens included vancomycin and 63.5% of IVASs were new outpatient initiations, rather than a continuation from inpatient antimicrobial treatments.

Hahn and colleagues reported that 57.5% of the new outpatients IVASs were classified as inappropriate. Among patients with a fistula or graft access type, inappropriate IVAS aggregate rates were lower compared with patients with a central line (P < .0001), and no significant difference was found between patients with a fistula compared with patients with a graft (P = .86).

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“A review of patients without a documented indication for an antimicrobial prescription should be conducted to validate the metric and understand how precisely it measures the burden of inappropriate intravenous antimicrobial prescribing in hemodialysis facilities,” Hahn said. “Additionally, regional differences in overall patterns of antimicrobial prescribing have been noted, so future studies may want to look at this in the hemodialysis setting, specifically related to inappropriate prescribing. Because we used NHSN data, it is possible for public health departments, dialysis companies, and quality improvement organizations across the country to replicate this analysis and evaluate the rate of inappropriate antimicrobial prescribing in hemodialysis facilities in their area.” – by Marley Ghizzone

Disclosures: The authors report no relevant financial disclosures.