D’Agata reviewed the antimicrobial usage and ASP programs in dialysis centers. 5 Chronic hemodialysis patients with central lines were noted to have the greatest rate of infections and antibiotic usage (6.4 per 100 patient months). The next highest group was dialysis patients with grafts (2.4 per 100 patient months), followed by patients with fistulas (1.8 per 100 patient months). Vancomycin was most commonly chosen for all antibiotic starts (73%). Interestingly, vancomycin was followed by cefazolin and third- and/or fourth-generation cephalosporin, which are risk factors for the emergence of multidrug-resistant, Gram-negative bacteria that are highly linked to increased morbidity and mortality rates. The U.S. Renal Data System stated in its 2009 report that the use of antibiotic therapy has increased from 31% in 1994 to 41% in 2007. 5
In reviewing inappropriate choices of antimicrobial prescribing, D’Agata compared prescriptions given to the Healthcare Infection Control Practices Advisory Committee to determine whether the correct antibiotic was chosen. In 164 vancomycin prescriptions, 20% were categorized as inappropriate. 5 In another study done by Zvonar and colleagues, 163 prescriptions of vancomycin were reviewed, and 12% were considered inappropriate. 6
Snyder and colleagues examined 278 patients on hemodialysis, and over a 1-year period, 32% of these patients received ≥ 1 antimicrobial with 29.8% of the doses classified as inappropriate. 7 The most common category for inappropriate prescribing of antimicrobials was not meeting the criteria for diagnosing infections (52.9% of cases). The second leading cause of inappropriate prescription for infections was not meeting criteria for diagnosing specific skin and skin-structure infections (51.6% of cases). Another common category was failure to choose a narrower spectrum antimicrobial prescription (26.8%). 7 Attention to the indications and duration of antimicrobial treatment accounted for 20.3% of all inappropriate doses. Correction of these problems with use of an ASP could reduce the patient’s exposure to unneeded or inappropriate antibiotics by 22% to 36% and decrease hospital costs between $200,000 to $900,000. 5
Rosa and colleagues discussed adherence to an ASP and the effects on mortality in hospitalized cancer patients with febrile neutropenia (FN). 8 A prospective cohort study was performed in a single facility over a 2-year period. Patients admitted with cancer and FN were followed for 28 days. The mortality rates of those treated with ASP protocol antibiotics were compared with those treated with other antibiotic regimens. One hundred sixty-nine patients with 307 episodes of FN were included. The rate of adherence to ASP recommendations was 53% with the mortality of this cohort 9.4% (29 patients). 8
Older patients were more likely to be treated according to ASP recommendations, whereas patients with comorbidities were not treated with ASP guidelines, Rosa and colleagues noted. 8 No explanation was given, but statistical testing did uphold these findings, ensuring that the results were correctly interpreted. The 28-day mortality during FN was related to several factors, including nonadherence with ASP recommendations ( P = .001) relapsing diseases stages ( P = .001), and time to antibiotic start therapy > 1 hour ( P = .001). Adherence to the ASP was independently associated with a higher survival rate ( P = .03), whereas mortality was attributable to infection in all 29 patients who died.