Intervention fails but still ‘provides a roadmap’ to reduce antimicrobial use, experts say
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An intervention researchers hoped would improve infection management did not significantly reduce antimicrobial use among nursing home residents with dementia, data showed.
However, experts said it provides a good starting point for curbing antibiotic overprescribing.
“Despite the need to align antimicrobial use at the end of life with goals of care, efforts to improve infection management in nursing homes have not integrated infectious disease and palliative care principles, nor have they focused on residents with advanced dementia,”
Susan L. Mitchell, MD, MPH, co-director of the Interventional Studies in Aging Center and the senior scientist at the Hinda and Arthur Marcus Institute for Aging Research in Boston, and colleagues wrote.
In a randomized study, 28 Boston-area nursing homes either participated in the intervention (n = 14) or provided routine care (n = 14) from Aug. 1, 2017, to April 30, 2020. The intervention integrated best practices for infectious diseases and palliative care for the management of suspected UTIs and lower respiratory infections (LRIs) in patients with advanced dementia. It included an in-person seminar and an online course, and providers also received management algorithms, communication strategies and feedback on their antimicrobial prescribing. The residents’ health care proxies also received a booklet about infections in residents with advanced dementia. In the final analysis, 199 residents were included in the intervention arm and 227 residents continued with routine care.
In-person or online training was completed by 88% of the targeted nursing home practitioners, according to the researchers.
“No restrictions were placed in either arm with regard to other antimicrobial stewardship, advance care planning, or palliative care programs,” Mitchell and colleagues wrote.
The researchers reported that regarding the trial’s primary outcome, there was a 33% reduction in antimicrobial prescriptions for suspected UTIs or LRIs for each person-year in the intervention cohort (0.55; 95% CI, 0.25-0.84) compared with the control cohort (0.82; 95% CI, 0.49-1.14), but the difference was not significant (adjusted marginal rate difference, –0.27; 95% CI, –0.71 to 0.17). This reduction was largely due to reduced antimicrobial use for LRIs, they said.
According to the researchers, the trial’s secondary outcomes of starting antimicrobials when minimal criteria were missing, bladder catheterizations, venous blood sampling and hospital transfers did not differ significantly between the intervention and control groups. Only the secondary outcome of chest radiography utilization was significantly lower in the intervention group (0.53; 95% CI, 0.24-0.83) than the control group (1.1; 95% CI, 0.65-1.55; adjusted marginal rate difference = –0.56; 95% CI, –1.1 to –0.03).
“Inadequate power and suboptimal implementation fidelity may have accounted for the nonsignificant findings,” Mitchell and colleagues wrote. “In addition, the intervention may have led to differential documentation of suspected infections between arms.”
However, according to the researchers, “signals of effectiveness, high adherence to training and the clinical importance of infection management in residents with advanced dementia” warrant further study.
In a related commentary, Shiwei Zhou, MD, and Preeti N. Malani, MD — both clinical professors of infectious diseases at the University of Michigan — said that logistical barriers to improving antibiotic prescribing in nursing homes have been well-documented, but few have tried to find solutions in the context of advanced dementia. They described the study by Mitchell and colleagues as “unique” and said the intervention “provides a roadmap to help curb inappropriate antibiotic use” when nursing homes can resume their focus on antimicrobial stewardship and not COVID-19.
References:
Mitchell SL, et al. JAMA Intern Med. 2021;doi:10.1001/jamainternmed.2021.3098.
Zhou S, Malani PN. JAMA Intern Med; 2021;doi:10.1001/jamainternmed.2021.3243.
Perspective
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Corneilius "Neil" J. Clancy, MD
Of course, we would have liked to have seen a statistically significant reduction in antibiotic use in the Mitchell study, since nursing home residents and patients with dementia are at high risk for excessive, unnecessary antibiotic exposure and antibiotic-resistant infections. These are especially challenging populations to find antibiotic stewardship interventions that work, which were not extensively studied in early years of the stewardship era. Had a larger trial taken place and compliance with guidelines and interventions been monitored, a statistically significant reduction in antibiotic use might have been achieved.
However, as a matter of concept, the authors did show that it is possible to reduce antibiotic use by 33% with a multifaceted intervention targeting practitioners, based on education and training.
Here at the Veterans Affairs Pittsburgh Health Care System, we were able to reduce and sustain reductions in inappropriate and overall antibiotic use with an intervention that included not only training and education, but also peer-comparison feedback from infectious disease physicians and pharmacists to practitioners in our ambulatory clinics and emergency department.
Our experience showed that even if we train people, put out guidelines and measure how closely the guidelines are being followed, feedback and interactions between infectious diseases practitioners and primary clinicians are crucial to optimizing antibiotic usage. There are many stewardship interventions underway nationally that are targeting previously understudied populations, including nursing home residents and persons with dementia. It will be exciting to monitor data from these interventions as they are published and presented at meetings.
Director of the extensively drug-resistant pathogen lab and mycology program
University of Pittsburgh
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