Antibiotic use, and misuse, in the nation's nursing homes has long been a concern for infectious disease professionals and antibiotic resistance experts.
According to the Centers for Disease Control and Prevention, an estimated 70% of nursing home residents receive one or more courses of antibiotics a year. The primary reasons for such frequent antibiotic use in long-term care is that residents are often frail and have underlying conditions that make them more vulnerable to bacterial infections, especially those involving the skin, urinary tract, and respiratory tract.
Yet studies have shown that anywhere from 40% to 75% of the antibiotics prescribed in nursing homes may be inappropriate, resulting in increased risk of adverse drug reactions, Clostridioides difficile infections, and colonization or infection with antibiotic-resistant organisms.
One group that is particularly susceptible to infections, and antibiotics, are residents with Alzheimer's or advanced dementia. This population presents a particular challenge for antibiotic stewardship for a variety of reasons, says Susan Mitchell, MD, MPH, a professor of medicine at Harvard Medical School and director of palliative care research at the Marcus Institute for Aging Research.
While infections are often a hallmark of the end-stage of advanced dementia, previous research by Mitchell has found that antibiotics are frequently prescribed for most suspected infections in advanced dementia patients in the absence of the minimum clinical criteria to support their use.
Furthermore, performing a full diagnostic evaluation, and prescribing antibiotics, may not provide much benefit nor align with the common goal of care for many of these patients —keeping them comfortable.
"For many of these patients…the main goal of care is comfort care," Mitchell said. "The decision has to consider what are the goals of care, and what are the risks and potential benefits of treating or not treating a suspected infection."
But that decision becomes complicated when family members or proxies, who are frequently the ones communicating for patients with Alzheimer's or advanced dementia, insist on antibiotics.
Intervention focused on education, communication
To investigate whether a multicomponent intervention focused on education and communication could improve the management of suspected infections in nursing home residents with advanced dementia, and reduce antibiotic use, Mitchell and a team of researchers conducted a cluster-randomized trial of 28 Boston-area nursing homes, 14 of which began implementing the intervention in August 2017. The results of the trial were published this week in JAMA Internal Medicine.
The intervention integrated best practices from infectious diseases and palliative care for managing suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) in patients with advanced dementia. The components, which targeted nurses and prescribing providers, included an in-person seminar, an online course, feedback reports on antibiotic prescribing, and posters and pocket cards with treatment algorithms for managing suspected UTIs and LRIs in advanced dementia patients.
Another component was advice for prescribers on how to have conversations with family members who insist that their loved ones get antibiotics, even when the clinicians don't agree.
"From prior work we did, we knew that some of the providers understood some of the caveats, and what you consider in treating these patients, but they were getting a lot of pressure from families to give antibiotics," Mitchell said.
Proxies and family members of residents also received a 6-page booklet about infections in residents with advanced dementia.
The primary outcome of the trial was antimicrobial treatment courses for suspected LRIs and UTIs per person-year among the 199 residents with advanced dementia in the 14 homes where the intervention was implemented, compared with 227 residents in the 14 nursing homes that continued routine care for suspected infections (the control arm). Secondary outcomes included antimicrobial prescriptions in the absence of minimal criteria for treatment per person-year, and burdensome procedures (such as chest x-rays or bladder catheterization) used to evaluate suspected infections.
Over the 12-month study period, 27.1% of residents in the intervention arm and 33.9% in the control arm received at least one antibiotic course for a suspected UTI or LRI. The adjusted marginal rate of antibiotic courses for suspected infections per person-year was 33% lower in the intervention arm (0.55; 95% confidence interval [CI], 0.25 to 0.84) vs the control arm (0.82; 95% CI, 0.49 to 1.14), but the difference was not significant (adjusted marginal rate difference, − 0.27; 95% CI, − 0.71 to 0.17) because of the way the study was designed.
"I think clinically this was an important reduction. Thirty-three percent is a lot, and most clinicians would agree that's a lot," Mitchell said. "But it didn't meet significance, we think, because the study was slightly underpowered."
The reduction in antibiotic use in the intervention arm was driven mainly by fewer antibiotics for LRIs, a finding Mitchell said was unexpected. Although she's not sure why this is the case, she suspects it's because there has been a focus in recent years on better UTI management in nursing home patients, and not as much work on LRIs.
"I am wondering if we just had less room to move the needle on UTIs because so much work has already been done," she said.
There was also a nonsignificant reduction in the adjusted marginal rates of antimicrobial courses when minimal clinical criteria were absent (adjusted marginal rate difference, − 0.05; 95% CI, − 0.35 to 0.24). One area where a significant reduction was observed in the intervention arm was the use of chest x-rays (adjusted marginal rate difference, − 0.56; 95% CI, − 1.10 to − 0.03). Mitchell said that reduction speaks to the fact that there was less aggressive management of LRIs in the nursing homes that implemented the intervention.
Another positive finding from the trial was the commitment to the intervention among staff members. A total of 342 practitioners (88.4%) and 288 nurses (95%) completed either the online course or the training seminar, with 63.8% and 65%, respectively, completing both.
"We were really heartened by the uptake of this intervention and adherence to the protocol," Mitchell said. "I think it spoke to the fact that this really is an issue that these nursing homes were dealing with and the administrators wanted to improve."
Intervention 'worthy of replication'
Although the findings indicated a nonsignificant reduction, Mitchell thinks the intervention can help nursing homes better manage suspected infections and prevent unnecessary antibiotic use in this vulnerable population.
"This is good practice, no matter what," she said. "If I was a nursing home administrator, I would introduce some of these educational materials for my providers, because it's good clinical care."
That opinion is echoed in an accompanying commentary by infectious disease specialists Shiwei Zhou, MD, and Preeti Malani, MD, of the University of Michigan.
"From a stewardship perspective, a low-cost, low-risk, scalable intervention that is associated with a reduction in inappropriate prescriptions is worthy of replication," they wrote. "Mitchell and colleagues have added a practical tool to the stewardship armamentarium, along with a poignant reminder of another urgent public health crisis that is yet to be addressed."
