English abstract
Introduction: Chronic kidney disease (CKD) is a global health challenge, with
a reported prevalence of around 10%. Both the incidence and prevalence of
Omani people progressing to chronic kidney disease category 5 (CKD G5) have
noticeably increased over the last 30 years. Prescribing for patients receiving
hemodialysis (HD) is challenging and complicated by polypharmacy,
comorbidities, and changes in clearance (cl) of medications. People with CKD
and those receiving renal replacement therapy (RRT) are prone to different
types of infections, especially those caused by multi-drug resistant (MDR)
organisms. The utilization of different antibiotics in HD is not fully understood.
Information about prescribing patterns may aid in identifying potential drugrelated problems, and preventing them.
Aim: Evaluation of antibiotics utilization patterns in patients receiving HD at
Sultan Qaboos University Hospital (SQUH), and to assess the dosage
appropriateness of the prescribed antibiotics.
Method: This was a retrospective study on a random sample of inpatients from
the dialysis unit at SQUH, who received an antibiotic during the period 1st of
January 2018 to 31st of December 2019. Data were extracted using the SQUH
TrakCare system, including patients' data, medical history, data related to HD,
and details of the prescribed antibiotics. Dosage appropriateness was assessed
by identifying the dosage and frequency of prescribed antibiotics and comparing
them with international guidelines, namely; Stanford Health Care Antimicrobial
Dosing Reference Guide (2020) and The Renal Drug Handbook (5th edition).
Results: Data of 287 patients were collected. 28.2% of which were re-admitted
again and required antibiotics. A total of 717 courses of antibiotics were
prescribed and administered during the study period. A total of 202 different
infections were diagnosed in 49.5% (142/287) of the patients. The most common
infections were respiratory tract infections (RTIs), which account for 24.8% of
the total infections, followed by blood stream infections (BSIs) with a prevalence
of 19.8%. A total of 173 (24%) courses were given as a single dose versus 544
(76%) courses as multiple doses. The most commonly prescribed parenteral
antibiotic was piperacillin+tazobactam (20%), while the most common
prescribed oral antibiotic was azithromycin (41.7%). For prophylaxis, cefazolin
(54.6%) was the main antibiotic prescribed, followed by amoxicillin+clavulanate
(16.0%). A total of 5 courses of antibiotics were administered as nebulization,
particularly, colistin (60.0%) and tobramycin (40.0%). Vancomycin and
aminoglycosides [amikacin (25.0%) & gentamicin (50.0%)] were prescribed as
catheter lock. A total of 26 courses of the antibiotics were prescribed for external
use, and the most commonly used antibiotic was mupirocin ointment (38.5%).
Only oral, injectable, and nebulized antibiotics (96.4%) were assessed for
VI
dosage inappropriateness. The overall dosing inappropriateness was 29.5%.
Vancomycin was the most common injectable antibiotic subjected to dosing
inappropriateness (19.8%; 38/192). However, trimethoprim+sulfamethoxazole
was more inappropriately prescribed among the oral route (28.6%; 2/7).
Conclusion: This study provides a useful summary of the common infections,
causative organisms, commonly prescribed antibiotics (injectable, oral,
nebulized, and topical), and their inappropriate use. The study reported an
alarming number of MDR organisms accounting for 34.5% of total isolated
bacteria and significant inappropriate dosing of antibiotics reaching 29.5%. Such
a study opens the door for the establishment of local guidelines for the improved
practice of antibiotics use in HD patients and effective prescribing.
