Addressing Antimicrobial Use in Nursing Home Residents

Antimicrobial use is often a topic that doesn’t get the attention it deserves. The world is wrapped in COVID-19 right now and has been since early 2020 which often means other health issues have been sidelined. In this situation though, those critical health topics cannot be ignored and now more than ever, we need to address them.

One particular health threat that exists on a global scale is antimicrobial resistance. Tough to tackle and harder to fundamentally address across so many sectors, it requires deep dives into what we’re doing and how we can drive change. One particularly vulnerable space for this is nursing homes and residents. Antimicrobials have a long known history of use in this setting and are often overly prescribed, which can translate to resistance infections.

To address this very issue and focus on the vulnerable residents experiencing Alzheimer disease and other dementias, a research team developed a cluster randomized clinical trial. Working across 28 Boston-area nursing homes and 426 residents, they sought to reduce antimicrobial use. All residents had advanced dementia and there were 199 in the intervention arm and 227 in the control arm.

This study was done from August 2017 to the end of April 2020. The goal was straightforward—utilizing a multicomponent intervention, could it reduce antimicrobial and intervention use for those with suspected urinary tract and lower respiratory tract infections? The authors noted that, “intervention components for targeting nursing home practitioners included: an in-person seminar, an online course, management algorithms (posters and pocket cards), proxy communication tips and feedback reports for prescribing antimicrobials. A booklet about infections in residents with advanced dementia was mailed to each resident’s proxy.”

Utilizing these strategies and measuring a primary outcome of antimicrobial treatment courses for suspected urinary tract infections or lower respiratory infections per person-years and the secondary outcomes were treatment for the suspected infections when minimal criteria for treatment was absent.

The authors reported that a majority of the intervention arm were female residents and 82% were White. “There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, −0.27 [95% CI, −0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs.

The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, −0.56 [95% CI, −1.10 to −0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners.”

While these interventions were important, that they ultimately revealed no significant change in antimicrobial use among those residents with advanced dementia. Despite the effort, there is a critical need to address the overuse of these medications in susceptible populations. Additional studies to identify effective interventions will be necessary to combat antimicrobial use for those residents in nursing homes with advanced dementia.