Antibiotic Prescribing Evaluation in an Outpatient Hemodialysis Clinic

Abstract

Background Empiric vancomycin treatment is frequently used in hemodialysis (HD) patients because of ease of administration when methicillin-resistant Staphylococcus aureus (MRSA) infection is suspected. Differing rates of MRSA indicate that empiric antibiotic treatment should be based on a center-specific antibiogram. Objective To develop a center-specific antibiogram, evaluate antibiotic prescribing patterns, and determine areas of improvement in infection treatment. Methods The antibiogram was constructed from culture and susceptibility (C&S) data from January through December 1999. Evaluation of prescribing habits was based on 3 criteria: (1) Hospital Infection Control Practices Advisory Committee and Centers for Disease Control and Prevention guidelines; (2) vancomycin for 1 dose followed by appropriate antibiotic based on C&S results; and (3) C&S obtained with more than 1 dose of antibiotic. Results HD was provided to 161 patients during the study period. Antibiotics were empirically prescribed 104 times in 62 different patients. Cultures were obtained 122 times, and 67 different isolates were identified. Gram-positive organisms and gram-negative organisms accounted for 77.6% and 22.4% of isolates, respectively. Gram-positive organisms were identified as Staphylococcus spp. (53.8%); 17.9% of the staphylococcal isolates were MRSA strains. No isolates of vancomycin-resistant enterococcus were identified. Based on the antibiogram, empiric antibiotic therapy within our center should be 1 dose each of vancomycin and an aminoglycoside. Empiric vancomycin was used 71 times. When criterion I is used, 12 prescriptions (16.9%) were considered appropriate. When criterion II and adjustment for MRSA reported for our center were used, 46 (64.8%) vancomycin prescriptions were considered appropriate. Forty-one patients had more than 1 dose of antibiotic therapy, and 18 (43.9%) of those patients did not have C&S data obtained as prescribed by criterion III. Areas of prescribing improvement include obtaining a C&S in all suspected infections prior to empiric therapy and a more aggressive antibiotic switch based on C&S results. Conclusions Antibiograms can be used to determine appropriate empric antibiotic therapy and identify areas of improvement.

Antibiotic lock: In vitro stability of vancomycin and four percent sodium citrate stored in dialysis catheters at 37°C

“…Citrate is now a popular and cost effective anticoagulant used for interdialytic CVC locking 27,28 . Vancomycin is a potent antibiotic for the management of the majority of CRB, those caused by gram‐positive organism 39 . A citrate and vancomycin lock is an intuitive and natural combination that is not routinely used due to an absence of data on its chemical stability.…”

Vancomycin Use in Patients Requiring Hemodialysis: A Literature Review

“…Vancomycin is one of the most commonly administered antibiotics in HD clinics (1), and its use has been extensively studied. Despite five decades of use, the single best method to administer vancomycin during HD remains elusive.…”

“…Clinical prescribing practices regarding vancomycin have been evaluated for appropriateness in the HD population (1,7). In studies evaluating vancomycin use (1,7), a modified version of the HICPAC guidelines for vancomycin prescribing was used in their evaluations (see below). MRSA infection was particularly common in the populations studied.…”

“…Manley et al. conducted an evaluation of antibiotic use at an outpatient HD clinic (1). An antibiogram created in the first phase of this study, showed that MRSA comprised almost half of all S. aureus organisms cultured.…”

“…Although most medications lose their stake in the medical market over that length of time, vancomycin is one exception to this rule. Due to its desirable pharmacokinetic characteristics and excellent coverage of many gram‐positive organisms, especially methicillin‐resistant Staphylococcus aureus (MRSA), vancomycin remains one of the most commonly administered antibiotics in hemodialysis (HD) patients (1,2).…”