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DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.
"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."
Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.
Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.
In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.
Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.
Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).
Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).
Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).
"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."
She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.
"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.
Dr. Wagner said that she had no relevant conflicts of interest to disclose.
DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.
"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."
Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.
Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.
In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.
Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.
Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).
Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).
Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).
"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."
She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.
"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.
Dr. Wagner said that she had no relevant conflicts of interest to disclose.
DENVER – Before a new protocol was implemented, antimicrobial dosing in patients receiving continuous renal replacement therapy varied and was adherent to evidence-based recommendations in about one-quarter of antimicrobial orders, results from a single-center study showed.
"For any kind of renal replacement therapy, there is always an uncertainty as to how much residual antibiotic is being removed, how much residual renal function the patient has, and how much of the antibiotic is actually staying within the patient for them to achieve therapeutic levels of the drug to combat their infection," Jamie Wagner, Pharm.D., said in an interview during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
"With renal replacement therapy, everything is dependent on the filter, the flow rate, and how much residual renal function the patient has. We set out to try to determine how well the interdisciplinary teams were adhering with dosing recommendations, defined as use of evidence-based dose for each CRRT [continuous renal replacement therapy] modality employed for the entire duration of antibiotics used during CRRT."
Dr. Wagner, an infectious diseases pharmacy fellow at the 802-bed Henry Ford Hospital, Detroit, and her associates evaluated 246 antimicrobial orders placed for 43 patients from November 2008 to May 2012. Patients were included in the analysis if they had an order placed for a beta-lactam, vancomycin, tobramycin, gentamicin, or daptomycin; if they received the drug in the ICU; and if they were on CRRT at the time the drug was administered. Patients receiving intermittent hemodialysis or peritoneal dialysis were excluded from the study.
Using medical records, the researchers evaluated demographics, CRRT modality, dates of changes in CRRT, and antibiotic dosing information. Each antibiotic order was evaluated for adherence to evidence-based dosing recommendation, which was the primary outcome of interest.
In August 2011, the Henry Ford Health System implemented an institutional guideline for antibiotic dosing in CRRT, which contained a summary of evidence-based dosing recommendations for the most common antimicrobial agents used in the ICU.
Of the 43 patients, 14 met study inclusion criteria before implementation of the guideline (group A), while the remaining 29 met inclusion criteria after implementation of the guideline (group B). The mean ages of patients in both groups were similar (55 years in group A vs. 59 years in group B), as were other variables.
Dr. Wagner reported that no differences were observed in antibiotic use between pre- and postguideline antibiotic orders. The three most commonly prescribed agents were vancomycin (32%), cefepime (21%), and aminoglycosides (15%). Following implementation of the guideline, overall adherence with evidence-based dosing recommendations improved from 24% to 49% between groups A and B, a difference which reached significance (P less than .001).
Four CRRT modalities changed significantly between groups A and B: continuous venovenous hemofiltration (CVVH) for 8-12 hours (24% vs. 0%, respectively); sustained, low-efficiency, daily diafiltration (SLEDD) for 8-12 hours with an F8 filter (29% vs. 6%); SLEDD for 8-12 hours with an F250 filter (14% vs. 1%); and SLEDD for 24 hours (11% vs. 75%).
Changes between modalities occurred in 13% of all orders assessed. Variables found to be associated with nonadherent orders were change of CRRT mode that resulted in a new recommended dose (7%), SLEDD for 8-12 hours (15%), and the use of any aminoglycoside (15%).
"Communication is key between all patient care providers on a daily basis," Dr. Wagner concluded. "At Henry Ford Hospital, providers must submit a new order for CRRT every single day for patients requiring antibiotic dosing. There needs to be communication about this between all providers involved in that patient’s care."
She acknowledged certain limitations of the study, including increased use of 24-hour SLEDD during the postguideline period, strict definition for adherence to the guideline, and the inability to systematically evaluate clinical response or residual function.
"Understanding factors associated with nonadherent orders can provide a starting point for clinicians to improve the antimicrobial use process in CRRT," she said.
Dr. Wagner said that she had no relevant conflicts of interest to disclose.
AT ICAAC 2013
