Determinants, Decision-Making and Outcomes of Antibiotic Use in Advanced Dementia

描述(由申请人提供)：晚期痴呆症是一种常见的、病态的和昂贵的疾病。感染性和发烧发作是终末期痴呆的特征，抗菌药被广泛开给死于这种疾病的患者。然而，目前尚不清楚抗菌治疗是否对这些绝症患者有任何延长生命或症状的好处，对他们来说，治疗的目标往往是缓解症状。此外，先前的工作表明，患有严重痴呆症的疗养院(NH)居民可能是这种情况下抗菌素耐药细菌(ARB)的储存库。抗菌药物的使用是导致ARB出现的主要因素；ARB是一个严重且迅速增长的公共卫生问题。NH居民也是ARB流入医院的原因之一。综上所述，抗菌剂在晚期痴呆中的广泛使用不仅从生命即将结束时的个人利益和负担的角度，而且从公共卫生的角度，对抗菌素耐药性的出现和传播提出了严重关切。对患有晚期痴呆症的NH居民不适当地开出抗菌药的程度从未被检查过。因此，痴呆症病原体耐药性和抗菌药暴露研究的首要目标是检查晚期痴呆症患者的抗菌素暴露，并进一步了解这种暴露如何有助于ARB的合并。通过对400名患有晚期痴呆症的NH居民和他们的卫生保健代理人进行前瞻性研究，每季度跟踪观察长达12个月，具体目标是：1.描述感染和发热发作的发生和管理，并确定潜在的不适当的抗微生物治疗；2.评估管理感染发作的决策，并确定与更高质量的决策相关的可修改的护理方面；以及3.表征ARB定植的基线流行率和动态(获得、丧失或持续)，并检查抗微生物暴露与ARB获得之间的关联。影响：拟议的工作将促进我们对晚期痴呆的NH居民使用抗微生物药物的理解，以及它对ARB的出现的贡献。目标1和目标2将确定导致过度使用和可能不适当使用的可修改因素，这些因素涉及：1.抗菌药物的启动和2.决策。AIM 3将研究这种风险敞口如何有助于ARB的收购。如果相当大比例的抗菌药物暴露是不适当的，无论是在满足公认的启动标准和共享决策方面，这些发现都将导致旨在优化抗菌药物使用和减少这些居民的ARB的战略。通过这种方式，改善对晚期痴呆症感染的管理，有可能通过促进为数百万死于这种疾病的美国人提供高质量的临终关怀，并通过解决NH环境中迅速增长的公共卫生威胁，来做出重要的临床和政策相关贡献。公共卫生相关性：拟议的工作将促进我们对患有严重痴呆症的疗养院居民中抗菌素暴露的了解，以及它对抗菌素耐药性细菌的出现的贡献，抗菌素耐药性细菌是美国一个严重的公共卫生问题。改善对晚期痴呆症感染的管理，通过促进对数百万患有这种疾病的美国人的高质量临终关怀，并减少疗养院环境中迅速增长的公共健康威胁，有可能做出重要的临床和政策相关贡献。

DESCRIPTION (provided by applicant): Advanced dementia is a common, morbid and costly condition. Infectious and febrile episodes are hallmarks of end-stage dementia, and antimicrobials are extensively prescribed to patients dying with this condition. However, it remains unclear as to whether antimicrobial treatment confers any life-prolonging or symptomatic benefit in these terminally ill individuals, for whom the goal of care is often palliation. Moreover, prior work suggests that nursing home (NH) residents with advanced dementia may be reservoirs for antimicrobial resistant bacteria (ARB) in this setting. Antimicrobial use is a main factor leading to the emergence of ARB; a critical and rapidly growing public health problem. NH residents also contribute to the influx of ARB into the hospital setting. Taken together, the widespread antimicrobial use in advanced dementia raises serious concerns not only from the perspective of individual benefits and burdens near the end-of-life, but also from a public health standpoint with respect to the emergence and spread of antimicrobial resistance. The extent to which antimicrobials are inappropriately prescribed to NH residents with advanced dementia has never been examined. Thus, the over-riding goals of the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD) are to examine antimicrobial exposure in advanced dementia and further our understanding as to how that exposure contributes to the mergence of ARB. By conducting a prospective study of 400 NH residents with advanced dementia and their health care proxies, followed on a quarterly basis for up to 12 months, the specific aims are: 1. to describe the occurrence and management of infectious and febrile episodes, and identify potentially inappropriate antimicrobial initiation, 2. to assess decision-making for the management of infectious episodes, and identify modifiable aspects of care associated with higher quality decision-making, and 3. to characterize the baseline prevalence and dynamics (acquisition, loss, or persistence) of ARB colonization, and examine the association between antimicrobial exposure with ARB acquisition. IMPLICATIONS: The proposed work will promote our understanding of antimicrobial use in NH residents with advanced dementia, and its contribution to the emergence ARB. Aims 1 and 2 will identify modifiable factors contributing to excessive and possibly inappropriate use related to: 1. antimicrobial initiation, and 2. decision-making. Aim 3 will examine how this exposure contributes to ARB acquisition. If a substantial proportion of antimicrobial exposure is inappropriate, both in terms of meeting accepted standards for initiation and shared decision-making, these findings will lead to strategies aimed at optimizing antimicrobial use, and reducing ARB in these residents. In this way, improving the management of infections in advanced dementia has the potential to make important clinical and policy-relevant contributions by promoting high quality end-of- life care for the millions of Americans dying with this condition, and by addressing a rapidly growing public health threat in the NH setting. PUBLIC HEALTH RELEVANCE: The proposed work will promote our understanding of antimicrobial exposure in nursing home residents with advanced dementia, and its contribution to the emergence of antimicrobial resistance bacteria, a serious public health issue in the US. Improving the management of infections in advanced dementia has the potential to make important clinical and policy-relevant contributions by promoting high quality end-of-life care for the millions of American dying with this condition, and reducing a rapidly growing public health threat in the nursing home setting.