Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities

Rates of multidrug-resistant (MDR) infections are continuing to rise in the United States and they are coupled with significant morbidity and mortality, as well as excess costs. With many of these infections encouraged by inappropriate prescribing practices, strong antimicrobial stewardship programs are imperative.

The implementation of such programs in outpatient dialysis facilities—where patients are at increased risk of colonization and infection—could lead to significant reductions in MDR infections, and, consequently, related deaths and costs, according to the results of a new analysis conducted by investigators from Brown University and the Cornerstone Research Group, from Ontario, Canada.

Patients who are receiving chronic hemodialysis are at high-risk of colonization and infection with MDR organisms. Treatment for these infections requires antibiotics, despite that antimicrobial exposure encourages both the emergence and dissemination of drug-resistant organisms.

“Antibiotic resistance can be amplified through the administration of antibiotics. It sounds counterintuitive that way, but we give antibiotics; they kill off susceptible bacteria, and what does that leave to grow? Resistant bacteria,” Jason Gallagher, PharmD, a clinical professor at Temple University School of Pharmacy, and Contagion^® ’s editor-in-chief, explained in a recent MDR Insights program.

“An expression I like to think of is nature abhors a vacuum,” he added. “If you have an area where previously susceptible bacteria exist after an antibiotic has been given to kill them, what’s left to grow are the resistant ones. And in this way, the use of antibiotics actually furthers resistance to those antibiotics.”

Inappropriate prescribing practices just add to the problem. The authors of the analysis estimated that up to 30% of antimicrobials administered in outpatient dialysis facilities are unnecessary or are not considered to be optimal based on national guidelines. As such, they postulated that the implementation of antimicrobial stewardship programs—which have been shown to reduce antibiotic use by 20% to 50% with substantial benefit in clinical outcomes—could be key to improving prescribing practices in these facilities.

To quantify the clinical and economic consequences of the implementation of antimicrobial stewardship programs in dialysis facilities nationwide, the investigators developed a health economic model which focused on total antimicrobial use, MDR-associated infections, infection-related mortality, and total costs. All patients on outpatient hemodialysis in the United States were considered in the analysis.

Event probabilities associated with antimicrobial dose appropriateness, colonization with MDR organisms post-antibiotic exposure, MDR-associated infections, and mortality, were gleaned from published literature as well as clinical opinion. Drug costs were obtained from RED BOOK and data associated with the types of antimicrobials administered were collected from the literature and used to estimate costs of empirical and continuing doses.

“The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical endpoints and cost outcomes,” the authors wrote.

On a national level, the team predicted the implementation of antimicrobial stewardship programs to result in 2,182 fewer infections caused by MDR organisms (a 4.8% reduction). Furthermore, the team predicated 629 fewer deaths associated with these infections (4.6% reduction), and an annual cost savings of $106,893,517 (5.0% reduction).

Based on these results, the authors contend that instituting these programs would lead to significant reductions in MDR infections as well as associated deaths and costs.

“This paper emphasizes the importance of improving antimicrobial prescribing in dialysis facilities in improving the health of patients on maintenance hemodialysis,” lead author of the study, Erika D’Agata, MD, MPH, Brown University, commented in a recent statement.