Advancing Antimicrobial Stewardship in Outpatient Dialysis Centers Using the Positive Deviance Process.

Antimicrobial resistance is a major growing problem fueled by inappropriate use of antimicrobials. Patients requiring maintenance hemodialysis are at especially high risk for infections caused by antimicrobial-resistant bacteria. The Centers for Disease Control and Prevention has recommended development and implementation of antimicrobial stewardship programs to combat the spread of resistant pathogens. This article describes in detail a multifaceted antimicrobial stewardship intervention that featured staff education and a behavioral change process, Positive Deviance, and its implementation in six outpatient hemodialysis units. Results of the intervention demonstrated a 6% month-to-month reduction in antimicrobial doses/100 patient months over the course of the 12 months intervention, with a decrease in mean antimicrobial doses from 22.6/100 to 10.5/100 patient months from the beginning to the end of the intervention period. These results demonstrate the effectiveness of this multifaceted intervention in engaging staff and improving antimicrobial prescribing patterns.

The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities.

BACKGROUND: Antimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%-35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed. OBJECTIVE: To quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.Study design and settingAn interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period. RESULTS: Implementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met. CONCLUSIONS: Within 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.