RESUMO
BACKGROUND: Patients receiving hemodialysis (HD) are at high risk of infections, including those caused by multidrug-resistant organisms. Given that antimicrobial exposure is a major risk factor for the emergence of these resistant organisms, minimizing inappropriate use is imperative. To optimize use, it is important to understand patterns of antimicrobial prescribing in this setting. OBJECTIVES: To measure antimicrobial use and to describe prescribing patterns among patients receiving outpatient HD. METHODS: A retrospective observational case series study was performed in an outpatient HD unit from February to April 2017. Adults for whom at least 1 antimicrobial was prescribed were included. The primary outcome was total antimicrobial days of therapy (DOT) per 1000 patient-days. Secondary outcomes were the characteristics of the antimicrobial prescriptions, in terms of antimicrobial class, indication, purpose, route, and prescriber group. RESULTS: Antimicrobials were prescribed for 53 (16%) of the 330 patients treated in the HD unit during the study period; the total number of prescriptions was 75. Antimicrobial use was 27.5 DOTs/1000 patient-days. Fluoroquinolones were the most frequently prescribed type of antimicrobial (n = 17, 23%), whereas the second most frequently prescribed were first-generation cephalosporins (n = 16, 21%). The most common indication was skin or soft-tissue infection (n = 14, 19%), followed by bloodstream infection (n = 13, 17%). Of the 75 antimicrobials, 48 (64%) were prescribed for empiric therapy, 19 (25%) for targeted therapy, and 8 (11%) for prophylaxis. Two-thirds of the antimicrobials prescribed (n = 50, 67%) were oral medications, and most (n = 72, 96%) were ordered by hospital prescribers. CONCLUSIONS: Antimicrobial use was common in this study setting, with 1 in 6 HD patients receiving this type of medication. The findings of this study create opportunities to standardize antimicrobial prescribing at the local level for common infections that occur in patients receiving outpatient HD.
CONTEXTE: Les patients sous hémodialyse (HD) présentent un risque élevé d'infections, y compris celles provoquées par des organismes multirésistants. Étant donné que l'exposition aux antimicrobiens est un facteur de risque majeur pour l'émergence de ces organismes résistants, il est impératif de minimiser l'utilisation inappropriée. Pour optimiser l'utilisation, il importe de comprendre les tendances de prescription d'antimicrobiens dans ce contexte. OBJECTIFS: Mesurer l'utilisation des antimicrobiens et décrire les schémas de prescription chez les patients recevant une HD ambulatoire. MÉTHODES: Une étude rétrospective de séries de cas a été réalisée dans une unité d'hémodialyse pour patients externes de février à avril 2017. Les adultes à qui au moins 1 antimicrobien avait été prescrit ont été inclus dans l'étude. Le paramètre d'évaluation principal était le nombre total de jours de traitement antimicrobien (JTA) pour 1000 jours-patients. Les paramètres secondaires étaient les caractéristiques des prescriptions d'antimicrobiens, en termes de classe d'antimicrobiens, d'indication, d'objectif, de voie d'administration et de groupe de prescripteurs. RÉSULTATS: Des antimicrobiens ont été prescrits à 53 (16 %) des 330 patients traités dans l'unité d'HD au cours de la période d'étude, pour un nombre total de prescriptions de 75. L'utilisation d'antimicrobiens était de 27,5 JTA/1000 jours-patients. Les fluoroquinolones étaient le type d'antimicrobien le plus fréquemment prescrit (n = 17, 23 %) et les céphalosporines de première génération (n = 16, 21 %) étaient le deuxième type. Une infection de la peau ou des tissus mous (n = 14, 19 %) était l'indication la plus courante, suivie d'une infection du sang (n = 13, 17 %). Sur les 75 antimicrobiens, 48 (64 %) ont été prescrits pour un traitement empirique, 19 (25 %) pour un traitement ciblé et 8 (11 %) pour une prophylaxie. Les deux tiers des antimicrobiens prescrits (n = 50, 67 %) étaient des médicaments oraux, et la plupart (n = 72, 96 %) ont été prescrits par des prescripteurs hospitaliers. CONCLUSIONS: L'utilisation d'antimicrobiens était courante dans le cadre de cette étude, où 1 patient sous HD sur 6 recevait ce type de médicament. Les résultats de cette étude créent des opportunités de normaliser la prescription d'antimicrobiens au niveau local pour les infections courantes qui surviennent chez les patients recevant une HD ambulatoire.
RESUMO
Background: There is a lack of clear benefit and a potential risk of bleeding with direct oral anticoagulant (DOAC) use in chronic kidney disease (CKD) and dialysis patients with atrial fibrillation. The objective of this study was to evaluate how treatment with DOACs affects stroke and bleeding outcomes compared with warfarin or aspirin. Methods: We conducted a systematic review of randomized controlled trials, cohort studies and case series, and searched electronic databases from 1946 to 2017. Studies evaluating stroke and bleeding outcomes with DOAC use in CKD and dialysis patients were included. Results: From 8008 studies, 10 met the inclusion criteria. For moderate CKD patients (estimated glomerular filtration rate <60 mL/min/1.73 m2), there was no difference in stroke outcomes between dabigatran 110 mg [hazard ratio (HR) 0.78, 95% confidence interval (95% CI) 0.51-1.21], rivaroxaban (HR 0.82-0.84, 95% CI 0.25-2.69) and edoxaban (HR 0.87, 95% CI 0.65-1.18) versus warfarin. Dabigatran (150 mg twice daily) and apixaban reduced risk of stroke or systemic embolism significantly more than warfarin for moderate CKD patients (HR 0.55, 95% CI 0.34-0.89 and HR 0.61, 95% CI 0.39-0.94, respectively). Edoxaban and apixaban were associated with reduced major bleeding events (HR 0.50-0.76) compared with warfarin. Rivaroxaban and dabigatran 110 mg and 150 mg showed no significant difference in major bleeding versus warfarin. In hemodialysis (HD) patients, there was no difference in stroke outcomes between apixaban, dabigatran [relative risk (RR) 1.71, 95% CI 0.97-2.99] or rivaroxaban (RR 1.8, 95% CI 0.89-3.64) versus warfarin. In HD patients, rivaroxaban and dabigatran were associated with an increased major bleeding risk (RR 1.45-1.76), whereas there was no major bleeding difference with apixaban compared to warfarin. Limitations: The heterogeneity of major bleeding and stroke definitions of the 10 included studies. Conclusions: Clinicians should continue to weigh the risk of stroke versus bleeding before prescribing DOACs in the CKD and dialysis population.
