Outpatient Antibiotic Prescribing Patterns for Adult End-Stage Renal Disease Patients in New York State.

IMPORTANCE Infections are important complications of end-stage renal disease (ESRD) with few studies having investigated oral antibiotic use. Inappropriate antibiotic prescribing can contribute to multi-drug resistant organisms (MDRO) and Clostridioides difficile (CDI) infections seen in ESRD. This study investigates antibiotic prescribing practices in ESRD across New York State (NYS). METHODS Retrospective case-control study from 2016 to 2017 of NYS ESRD and non-ESRD patients analyzing Medicare part B billing codes, 7 days before and 3 days after part D claims. Frequencies of each infection, each antibiotic, dosages, and the antibiotics associated with infections were assessed using chi-square analysis. A NYS small dialysis organization comprising approximately 2200 patients was also analyzed. Outcomes measured were the frequencies of infections and of each antibiotic prescribed. Incidence measures included antibiotics/1000 and individuals receiving antibiotics/1000. RESULTS 48,100 infections were treated in 35,369 ESRD patients and 2,544,443 infections treated in 3,777,314 non-ESRD patients. ESRD patients were younger, male, and African American. ESRD and non-ESRD patients receiving antibiotics was 520.29/1000 and 296.48/1000, respectively (p<0.05). The prescription incidence was 1359.95/1000 ESRD vs 673.61/1000 non-ESRD patients. In 36%, trimethoprim-sulfamethoxazole dosage was elevated by current ESRD guidelines. Top infectious categories included non-specific symptoms, skin, and respiratory for ESRD; and respiratory, nonspecific symptoms, and genitourinary in non-ESRD. CONCLUSIONS This study Identifies issues with appropriate antibiotic usage stressing the importance of antibiotic education to nephrologist and non-nephrologist providers. It provides support for outpatient antibiotic stewardship programs.

[1]  S. Coffin,et al.  Inappropriate intravenous antimicrobial starts: An antimicrobial stewardship metric for hemodialysis facilities , 2019, Infection Control & Hospital Epidemiology.

[2]  Arsh K Jain,et al.  Nephrology comanagement and the quality of antibiotic prescribing in primary care for patients with chronic kidney disease: a retrospective cross-sectional study. , 2019, Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association.

[3]  Rachel F. Eyler,et al.  Clinical Pharmacology of Antibiotics. , 2019, Clinical journal of the American Society of Nephrology : CJASN.

[4]  D. Lisi Outpatient Antibiotic Prescribing for Older Adults in the United States: 2011 to 2014 , 2019, Journal of the American Geriatrics Society.

[5]  S. Lapinsky,et al.  Long-Term Effects of Phased Implementation of Antimicrobial Stewardship in Academic ICUs: 2007–2015* , 2019, Critical care medicine.

[6]  J. Linder,et al.  Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study , 2019, British Medical Journal.

[7]  E. D’Agata,et al.  Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model. , 2018, Clinical journal of the American Society of Nephrology : CJASN.

[8]  M. Severo,et al.  Emergency surgeons’ perceptions and attitudes towards antibiotic prescribing and resistance: a worldwide cross-sectional survey , 2018, World Journal of Emergency Surgery.

[9]  E. D’Agata Addressing the Problem of Multidrug-Resistant Organisms in Dialysis. , 2018, Clinical journal of the American Society of Nephrology : CJASN.

[10]  N. Stone,et al.  Outpatient Antibiotic Prescribing Among Older Adults in the United States, 2011 to 2014 , 2017, Journal of the American Geriatrics Society.

[11]  P. Patel,et al.  The Making Dialysis Safer for Patients Coalition: A New Partnership to Prevent Hemodialysis-Related Infections. , 2018, Clinical journal of the American Society of Nephrology : CJASN.

[12]  Hyung Koo Kang,et al.  Proposed risk factors for infection with multidrug-resistant pathogens in hemodialysis patients hospitalized with pneumonia , 2017, BMC Infectious Diseases.

[13]  J. Coresh,et al.  CKD and Risk for Hospitalization With Infection: The Atherosclerosis Risk in Communities (ARIC) Study. , 2017, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[14]  K. Buising,et al.  Patterns of use and appropriateness of antibiotics prescribed to patients receiving haemodialysis: an observational study , 2017, BMC Nephrology.

[15]  A. Fauci,et al.  Antimicrobial Resistance. , 2016, JAMA.

[16]  L. Rice,et al.  Vancomycin-resistant enterococci colonization among dialysis patients: a meta-analysis of prevalence, risk factors, and significance. , 2015, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[17]  Arjun Srinivasan,et al.  Core elements of hospital antibiotic stewardship programs from the Centers for Disease Control and Prevention. , 2014, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[18]  Daniella Meeker,et al.  Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial. , 2014, JAMA internal medicine.

[19]  S. Cosgrove,et al.  Antimicrobial resistance: a global view from the 2013 World Healthcare-Associated Infections Forum , 2013, Antimicrobial Resistance and Infection Control.

[20]  Erika M C D'Agata,et al.  Antimicrobial Use and Stewardship Programs Among Dialysis Centers , 2013, Seminars in dialysis.

[21]  S. Kosa,et al.  The Economics of Hemodialysis Catheter‐Related Infection Prophylaxis , 2013, Seminars in dialysis.

[22]  P. Patel,et al.  Antimicrobial Use in Outpatient Hemodialysis Units , 2013, Infection Control &#x0026; Hospital Epidemiology.

[23]  Marcello Tonelli,et al.  Associations between hemodialysis access type and clinical outcomes: a systematic review. , 2013, Journal of the American Society of Nephrology : JASN.

[24]  S. Lapinsky,et al.  An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients , 2012, Critical Care.

[25]  R. Thadhani,et al.  Prevalence and outcomes of antimicrobial treatment for Staphylococcus aureus bacteremia in outpatients with ESRD. , 2012, Journal of the American Society of Nephrology : JASN.

[26]  R. Wolfe,et al.  Facility hemodialysis vascular access use and mortality in countries participating in DOPPS: an instrumental variable analysis. , 2009, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[27]  E. D’Agata,et al.  Multidrug-resistant gram-negative bacteria among patients who require chronic hemodialysis. , 2008, Clinical journal of the American Society of Nephrology : CJASN.

[28]  A. Bleyer Use of antimicrobial catheter lock solutions to prevent catheter-related bacteremia. , 2007, Clinical journal of the American Society of Nephrology : CJASN.

[29]  A. Collins,et al.  Infection-related hospitalization rates in pediatric versus adult patients with end-stage renal disease in the United States. , 2007, Journal of the American Society of Nephrology : JASN.

[30]  M. Alter,et al.  Recommendations for preventing transmission of infections among chronic hemodialysis patients. , 2001, MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports.

[31]  M. Perazella,et al.  Hyperkalemia in Hospitalized Patients Treated with Trimethoprim-Sulfamethoxazole , 1996, Annals of Internal Medicine.