The population of chronic hemodialysis (CHD) is rapidly growing. Rates of infections caused by antimicrobial-resistant bacteria (ARB) are among the highest in this patient population. Antimicrobial use is the main risk factor for the emergence and spread of ARB. There is a paucity of data quantifying antimicrobial use and inappropriate prescribing patterns among CHD patients, a priority population for the Agency of Healthcare Research and Quality. Comprehensive antimicrobial stewardship programs, specifically targeting this population in out-patient dialysis units, have not been developed. We initiated a pilot study in two out-patient dialysis units to quantify and characterize inappropriate prescribin of antimicrobials. Our preliminary data demonstrated that 27.5% of antimicrobial doses were prescribed inappropriately, as per national guidelines. Third/fourth generation cephalosporins, followed by vancomycin, were the most common antimicrobials prescribed inappropriately. The three key categories of inappropriate prescribing were a] national consensus criteria for diagnosing an infection were not met, b] lack of de-escalation of antimicrobial therapy and c] surgical prophylaxis for hemodialysis access-related procedures were continued e24 hours post-procedure. In this proposal we will develop, implement and demonstrate the effectiveness of an antimicrobial stewardship program in reducing antimicrobial prescribing and inappropriate prescribing in out-patient dialysis units. This program will include an educational intervention and both system and social/behavioral change strategies. The latter will involve the implementation of the Positive Deviance approach. An interrupted time series design will be used with monthly data collection during the12-month pre-intervention period and the 12- month post-intervention period.
The specific aims of this proposal are:
Aim 1 -To demonstrate the effectiveness of an antimicrobial stewardship program in reducing antimicrobial use in out-patient hemodialysis units.
Aim 2 - To demonstrate the effectiveness of an antimicrobial stewardship program in reducing inappropriate antimicrobial use in out-patient hemodialysis units.
Aim 3 - To demonstrate the cost-effectiveness of this antimicrobial stewardship program. Demonstrating the efficacy of this antimicrobial stewardship program will provide an unmet and long overdue need in the CHD population and will ultimately improve health outcomes in this patient population by reducing the prevalence of ARB and ARB infections.

Public Health Relevance

Limiting the emergence and spread of antimicrobial-resistant bacteria among patients requiring chronic hemodialysis, by improving antimicrobial prescribing patterns, will decrease the morbidity and mortality of this patient population. The benefits may also extend to other patient population both in the community and the hospital setting.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (HSQR)
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Gray, Darryl T
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Rhode Island Hospital
United States
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D'Agata, Erika M C; Tran, Diana; Bautista, Josef et al. (2018) Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model. Clin J Am Soc Nephrol 13:1389-1397
D'Agata, Erika M C (2018) Addressing the Problem of Multidrug-Resistant Organisms in Dialysis. Clin J Am Soc Nephrol 13:666-668
Snyder, Graham M; McCoy, Christopher; D'Agata, Erika M C (2017) Quantifying Antimicrobial Exposure: Hazards in Populations With End-Stage Renal Disease. Infect Control Hosp Epidemiol 38:360-363
Snyder, Graham M; Patel, Priti R; Kallen, Alexander J et al. (2016) Factors associated with the receipt of antimicrobials among chronic hemodialysis patients. Am J Infect Control 44:1269-1274
Wares, Joanna R; Lawson, Barry; Shemin, Douglas et al. (2016) Evaluating Infection Prevention Strategies in Out-Patient Dialysis Units Using Agent-Based Modeling. PLoS One 11:e0153820
Cunha, Cheston B; D'Agata, Erika M C (2016) Implementing an antimicrobial stewardship program in out-patient dialysis units. Curr Opin Nephrol Hypertens 25:551-555