March 21, 2013
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Inappropriate antimicrobial prescriptions common among hemodialysis outpatients

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Nearly one-third of parenteral antimicrobial use among patients in outpatient hemodialysis units was classified as inappropriate, researchers reported in Infection Control and Hospital Epidemiology.

“To date, there have been very little data reported on antimicrobial prescribing practices in the hemodialysis setting,” Graham Snyder, MD, of the division of infectious diseases at Beth Israel Deaconess Medical Center in Boston, told Infectious Disease News. “From nationwide data collected through the United States Renal Data System, we know that approximately 40% of patients receiving chronic hemodialysis have at least one billing claim for an antimicrobial each year and that vancomycin constitutes about two-thirds of prescribed antimicrobials. Our data are consistent with this.”

The researchers retrospectively analyzed the rate of parenteral antimicrobial use in two outpatient hemodialysis units from September 2008 to July 2011. They also prospectively evaluated the indication and appropriateness of antimicrobial doses from August 2010 to July 2011.

During the retrospective period, there were 32.9 doses of parenteral antimicrobials used per 100 patient-months. During the prospective period, there were 1,003 antimicrobial doses prescribed. Among these, 926 had information on the indication for administration and 276 (29.8%) of the doses were considered inappropriate.

The most common reason that the doses were considered inappropriate was that the criteria for infection were not met, which comprised 52.9% of the inappropriate doses. The second most common reason was that a more narrow-spectrum antimicrobial was not chosen: This was true for 26.8% of the inappropriate doses. For the remaining inappropriate doses, the criteria for surgical prophylaxis were not met.

The most common antibiotic used was vancomycin, which also was the most common inappropriately prescribed antimicrobial: 207 of 556 vancomycin doses were inappropriate. Third- or fourth-generation cephalosporins, as well as cefazolin, were the next most common inappropriately prescribed antimicrobial.

“There are several antimicrobial stewardship interventions that dialysis units could consider as part of their infection prevention planning,” Snyder said. “First, dialysis units should be aware of how frequently antimicrobials are being prescribed. The metric we used in our study — number of doses per patient-month — can be used to look at prescribing trends in units. Dialysis units should also consider evaluating their indications for antimicrobial use.”

Snyder said that some of the indication-related interventions include: obtaining bacterial cultures and using those results to tailor treatment; developing evidence-based local treatment guidelines for common conditions; and limiting prophylaxis for invasive procedures to selected appropriate procedures and for limited peri-procedural duration.”

Disclosure: Snyder reports no relevant financial disclosures.