Infectious Disease

The intervention fails, but still offers “a roadmap” to reduce antimicrobial use, say experts

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An intervention that the researchers hoped would improve infection management did not significantly reduce antimicrobial use in nursing home residents with dementia, the data showed.

However, according to experts, it provides a good starting point to curb antibiotic overdose.

Reference: Mitchell SL, et al. JAMA Intern Med. 2021; doi: 10.1001 / jamainternmed.2021.3098.

“Despite the need to align end-of-life antimicrobial use with care goals, efforts to improve infection management in nursing homes have not incorporated the principles of infectious diseases or palliative care, nor have they focused on residents with advanced dementia.”

Susan L. Mitchell, MD, MPH, Co-director of the Interventional Studies in Aging Center and senior researcher at the Hinda and Arthur Marcus Institute for Aging Research in Boston, and colleagues wrote.

In a randomized study, 28 nursing homes in the Boston area either took part in the intervention (n = 14) or provided routine care from August 1, 2017 to April 30, 2020 (n = 14). The intervention integrated infectious disease best practices and palliative care for the management of suspected urinary tract infections and lower respiratory tract infections (LRIs) in patients with advanced dementia. It included a face-to-face seminar and an online course, and providers also received management algorithms, communication strategies, and feedback on their antimicrobial prescribing. Healthcare officers also received a brochure about infections in residents with advanced dementia. Ultimately, 199 residents were accepted into the intervention arm and 227 residents continued to receive regular care.

According to the researchers, 88% of targeted nursing home practitioners completed in-person or online training.

“Neither arm placed any restrictions on other antimicrobial administration, advance planning, or palliative care programs,” wrote Mitchell and colleagues.

Researchers reported that relative to the primary endpoint of the study, a 33% reduction in antibiotic prescriptions for suspected UTIs or LRIs for each person-year in the intervention cohort (0.55; 95% CI, 0.25-0.84 ) compared to 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 That reduction was largely due to the reduced use of antimicrobials for LRIs, they said.

According to the researchers, the secondary results of the study of starting antibiotics in the absence of minimal criteria, urinary catheterizations, venous blood draws, and hospital transfers did not differ significantly between the intervention and control groups. Only the secondary endpoint of the chest x-ray was significantly lower in the intervention group (0.53; 95% CI 0.24-0.83) than in the control group (1.1; 95% CI 0.65-1, 55; adjusted marginal frequency difference = -0.56; 95th). % CI, -1.1 to -0.03).

“Poor performance and sub-optimal implementation fidelity may have been responsible for the insignificant results,” wrote Mitchell and colleagues. “In addition, the intervention may have led to different documentation of suspected infections between the arms.”

According to the researchers, however, “signals of effectiveness, high training adherence and the clinical importance of infection management in residents with advanced dementia” warrant further studies.

In a related comment Shiwei Zhou, MD, and Preeti N. Malani, MD – both clinical professors of infectious diseases at the University of Michigan – said logistical barriers to improving antibiotic prescribing in nursing homes are well documented, but few have tried to find solutions related to advanced dementia. They called the Mitchell and colleagues study “unique” and said the intervention “provides a roadmap to curb inappropriate antibiotic use” if nursing homes can focus on antimicrobial responsibility rather than 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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Cornelius (Neil) J. Clancy, MD)

Cornelius (Neil) J. Clancy, MD

Of course, we would have liked a statistically significant reduction in antibiotic use in the Mitchell study, since nursing home residents and patients with dementia are at high risk of excessive, unnecessary antibiotic exposure and antibiotic-resistant infections. This is a particular challenge for the population to find effective antibiotic stewardship interventions that were not fully explored in the early years of the stewardship era. If a larger study had taken place and compliance with guidelines and interventions had been monitored, a statistically significant reduction in the use of antibiotics would have been possible.

In principle, however, the authors showed that it is possible to reduce antibiotic consumption by 33% with a versatile intervention aimed at practitioners based on education and training.

Here at the Veterans Affairs Pittsburgh Health Care System, we were able to reduce inappropriate and general antibiotic use with an intervention that included not only education and training, but feedback from infectious disease doctors and pharmacists to doctors in our outpatient departments and the emergency room.

Our experience has shown that even when we train people, issue guidelines and measure how closely the guidelines are being followed, feedback and interactions between infectiologists and primary care physicians are critical to optimizing antibiotic use. At the national level, many stewardship interventions targeting under-researched populations, including nursing home residents and those with dementia, are ongoing. It will be exciting to see data from these interventions as they are published and presented at meetings.

Cornelius (Neil) J. Clancy, MD

Professor of Medicine
Director of the Laboratory for Largely Resistant Pathogens and the Mycology Program
University of Pittsburgh

Disclosure: Clancy reports that he has received researcher-initiated research grants from Astellas, Cidara, Melinta, Merck, serves on advisory boards or for Astellas, Cidara, the Medicines Company, Merck, Needham & Company, Qpex, Scynexis, Shionogi and as a speaker at sponsored Symposia is operated by Merck and T2Biosystems.

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