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、昂贵的疾病。传染性和发热发作是终末期痴呆的标志，对死于此病的患者广泛开抗生素。然而，目前尚不清楚抗菌素治疗是否能给这些绝症患者带来任何延长生命或症状上的益处，对他们来说，护理的目标往往是缓解。此外，先前的研究表明，在这种情况下，患有晚期痴呆症的养老院（NH）居民可能是耐药细菌（ARB）的宿主。抗菌药物的使用是导致ARB出现的主要因素；一个严重和迅速增长的公共卫生问题。NH居民也促使ARB涌入医院环境。综上所述，在晚期痴呆症中广泛使用抗菌素不仅从生命末期的个人利益和负担的角度来看，而且从公共卫生的角度来看，抗菌素耐药性的出现和传播也引起了严重关切。在何种程度上抗菌剂是不适当的规定，以NH居民与晚期痴呆从未被检查过。因此，痴呆症中病原体耐药性和抗微生物药物暴露研究（SPREAD）的首要目标是检查晚期痴呆症中的抗微生物药物暴露，并进一步了解这种暴露如何促进ARB的合并。通过对400名患有晚期痴呆症的新罕布什尔州居民及其保健代理进行前瞻性研究，每季度跟踪长达12个月，具体目标是：描述感染和发热发作的发生和管理，并确定可能不适当的抗菌素起始。2 .评估传染性发作管理的决策，并确定与更高质量决策相关的护理可修改方面；表征ARB定植的基线流行率和动态（获得、丧失或持续），并检查抗菌药物暴露与ARB获得之间的关系。建议的工作将促进我们对NH晚期痴呆患者抗菌药物使用的理解，及其对ARB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改变因素，涉及：1。2.抗菌起始；决策。目的3将研究这种暴露如何有助于ARB的获取。如果相当大比例的抗菌素暴露是不适当的，无论是在满足公认的开始标准还是共同决策方面，这些发现将导致旨在优化抗菌素使用的策略，并减少这些居民的ARB。通过这种方式，改善晚期痴呆症感染的管理有可能通过促进对数百万死于这种疾病的美国人的高质量临终关怀，并通过解决NH环境中快速增长的公共卫生威胁，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老年痴呆症患者抗菌药物暴露的理解，及其对抗菌药物耐药性细菌出现的贡献，这是美国一个严重的公共卫生问题。改善晚期痴呆患者的感染管理有可能对临床和政策做出重要贡献，为数百万死于这种疾病的美国人提供高质量的临终关怀，并减少养老院环境中快速增长的公共卫生威胁。

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.