Antimicrobial Stewardship Programs Reduce Infections, Mortality in Outpatient Dialysis Centers

Implementation of antimicrobial stewardship programs in outpatient dialysis centers reduce infections caused by multidrug-resistant organisms, including Clostridium difficile.

Antimicrobial stewardship programs implemented in outpatient dialysis facilities may reduce infections caused by Clostridium difficile and multidrug-resistant organisms, according to a recent study. Additionally, the investigators found that stewardship programs may also reduce infection-related deaths and overall health care costs.

The investigators developed a decision analytic model based on antimicrobial use, with a focus on the clinical and economic effects of implementing an antimicrobial stewardship program in outpatient dialysis centers across the nation. They then performed a cost-consequence analysis and calculated the clinical and economic benefits over a 1-year period. Analyses were focused on patients receiving hemodialysis on an outpatient basis in the United States. The primary outcomes included total antimicrobial use, infections as a result of multidrug-resistant organisms and C difficile, infection-related mortality, and total health care costs.

A total of 365,566 patients with end-stage kidney disease recorded in the US Renal Data System records received outpatient hemodialysis in the United States in 2009. During the 1-year period of the analysis, a total of 120,454 suspected infection cases were identified. The investigators found that implementation of antimicrobial stewardship programs in outpatient hemodialysis facilities resulted in approximately 2182 fewer infections as caused by C difficile and multidrug-resistant organisms.

Additionally, implementation of the program was predicted to result in 629 fewer infection-related deaths and an estimated cost savings of $106,893,517 per year. Inputs that increased the number of treated patients or the number of high-cost infections resulted in the largest effects of implementation. Reduction of unnecessary doses of broad-spectrum cephalosporins, cefazolin, and vancomycin was also associated with increases in implementation benefits.

“The primary benefit of any model is that it supports clinical decision making using a transparent process and is a tool that allows exploration of the effect of parameter uncertainty,” the investigators wrote. “The main limitation of any model is that it combines data from multiple sources and requires assumptions regarding the comparability of data. This study is, therefore, a useful tool for decision makers conducting hypothesis generation and testing, and it can guide future research activities, including probabilistic sensitivity analyses.”

The model used in this study did not include the costs associated with implementing an antimicrobial stewardship program, representing a potential limitation of the analysis. Considering this study focused on stewardship programs implemented in outpatient dialysis facilities, the investigators suggest these findings may not be entirely generalizable across other centers in the country.

“The model was most sensitive to changes in clinical input parameters, including probabilities of acquiring de novo colonization with multidrug-resistant organisms given antimicrobial exposure, empirical and/or continuous antimicrobial treatment being appropriate, and acquiring a multidrug-resistant organism infection; it was least sensitive to assumptions regarding actual costs of antimicrobials,” study researcher Erika MC D’Agata, MD, of Brown University, told MD Magazine® in an interview. “These findings emphasize the importance of reducing unnecessary antimicrobial use and its negative downstream effects.”

The study, “Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model,” was published in the Clinical Journal of the American Society of Nephrology.