Can Education Tackle Poor Antibiotic Prescribing in Nursing Homes?
An educational intervention to cut inappropriate antibiotic use for suspected urinary tract infections (UTIs) and lower respiratory tract infections among nursing home residents with advanced dementia had a limited impact in a cluster randomized trial. The multicomponent TRAIN-AD intervention reduced such prescribing by 33% per person-year compared with usual care (adjusted marginal rate difference 0.27, 95% CI 0.71 to 0.17), according to Susan L. Mitchell, MD, of the Hinda and Arthur Marcus Institute for Aging Research in Boston, and colleagues. While not statistically significant, that magnitude of reduction "would likely be considered meaningful by most clinicians caring for residents with advanced dementia," the researchers reported in JAMA Internal Medicine. However, the reduction was primarily attributable to lower respiratory tract infections, while prescribing for suspected UTIs remained stable, they noted. Among the secondary outcomes, only use of chest radiography was significantly lower in the intervention arm (adjusted marginal rate difference 0.56, 95% CI1.10 to 0.03). Antimicrobials prescribed in the absence of minimal criteria, bladder catheterizations, venous blood sampling, hospital transfers, and 12-month mortality did not differ between the study groups. The study builds on previous observations of increased antibiotic exposure among people with advanced dementia, especially during the 2 weeks before death, and its tendency to prolong survival but not improve comfort, Shiwei Zhou, MD, and Preeti Malani, MD, both of the University of Michigan in Ann Arbor wrote in an accompanying editorial. Given the lack of high-quality clinical trials in this area, "the results show compelling evidence that a low-cost, multicomponent intervention can lead to clinically meaningful improvement in antimicrobial prescribing," they wrote. "From a stewardship perspective, a low-cost, low risk, scalable intervention that is associated with a reduction in inappropriate antibiotic prescriptions is worthy of replication," Zhou and Malani concluded. Infection management in nursing homes overall is often "characterized by antimicrobial misuse, emergence of multidrug resistant organisms, use of burdensome procedures, and failure to consider goals of care," such as comfort, which should take precedence, Mitchell's group noted. Furthermore, implementation of recently issued CDC guidelines for antimicrobial stewardship in nursing homes has been inconsistent, they added. Their study was conducted at 28 Boston-area nursing homes for their 426 residents with any type of dementia who had a Global Deterioration Scale score of 7 on the 7-point scale and a length of stay greater than 90 days. The 199 residents in the intervention arm had an average age of 88, while the 227 residents in the control arm averaged 85. Both groups included about 83% women, and more than 80% of participants were white. There was a high practitioner adherence to the training components of the intervention, which merged best practices from infectious diseases and palliative care, with 88.4% of clinicians taking the online course or in-person training seminar. The intervention was delivered to nurses working with advanced dementia residents for at least two shifts weekly and to prescribing clinicians, including physicians, nurse practitioners, and physician assistants. Best infectious disease-related practices focused on minimal clinical criteria for empirical treatment with antimicrobial initiation adapted for long-term care residents whose dementia prevents them from reliably communicating certain symptoms, such as dysuria. Palliative care best practices focused on integrating residents' preferences into treatment decisions and optimizing communication with their health care proxies. These were delivered through an in-person seminar, an online course, posters and pocket cards on management algorithms, proxy communication tips, and feedback reports for prescribing antimicrobials. As well, each resident's proxy received an educational booklet on infections in residents with advanced dementia. Study authors noted limitations, including that the findings may not be generalizable to the general public, potential lack of statistical power, and possible variations in documentation of suspected infections between arms of the trial.