# Trial to Reduce Antimicrobial Use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD)

> **NIH NIH R37** · HEBREW REHABILITATION CENTER FOR AGED · 2021 · $172,300

## Abstract

The advanced stage of Alzheimer’s disease and other dementias is characterized by the onset infections,
which prior work suggests are widely mismanaged. Antimicrobials are extensively prescribed, most often
without evidence to support a bacterial infection. Antimicrobial exposure is the main factor leading to multidrug-
resistant organisms (MDROs); a growing public health threat. Moreover, the benefits of antimicrobials remain
unclear for patients with advanced dementia, for whom infections are often a terminal event and comfort is
most commonly the goal of care. In 2015, our group completed a prospective study of nursing home (NH)
residents with advanced dementia, the Study of Pathogen Resistance and Exposure to Antimicrobials in
Dementia (SPREAD) (parent NIH R01 for this competing renewal). Antimicrobials were prescribed for 72% of
suspected infections, but only 44% episodes met guideline-based criteria for treatment. Criteria were more
likely to be met when proxies were counseled about antimicrobials. Two-thirds of residents were colonized with
MDROs. Antimicrobial use was the major risk factor for MDRO acquisition. Motivated by these findings, the PIs
conducted a pilot study (NIH R21) of an intervention to improve management of suspected urinary (UTIs) and
lower respiratory tract infections (LRIs). With this foundation, the goal of this proposal, TRAIN-AD (Trial to
Reduce Antimicrobial Use In Nursing home residents with Alzheimer’s disease and other Dementias), is to
conduct a cluster randomized controlled trial of the intervention among 480 residents with advanced dementia
(N=240/arm) in 16 Boston-area NHs (N=8/arm). The intervention has two main components: 1. Provider
Training: In-person training, on-line course, management algorithms, and prescribing feedback, and 2. Proxy
Education: booklet. Unlike most antimicrobial stewardship programs, the intervention merges best practices in
infectious diseases and palliative care, and targets a unique population for whom the need to improve infection
management is particularly compelling. The Aims are to compare the following 12-month outcomes between
residents in the intervention and control arms (usual care) related to suspected UTIs and LRIs: Aim 1. total
number of antimicrobial courses/person-year (10 outcome); Aim 2. number of antimicrobial courses prescribed
when guideline-based criteria for treatment are absent/person-year (20 outcome), and Aim 3. i. advance care
planning about infection management, and ii. burdensome procedures/person-days used to evaluate these
episodes/person-year (20 outcomes). IMPLICATIONS: Prior work by our group has demonstrated a critical
need to improve the quality of care for suspected infections in advanced dementia patients. A cluster RCT of
an intervention to optimize infection management is the next logical step. This proposal addresses 3 federal
research priorities: Alzheimer’s disease, palliative care, and antibiotic stewardship. Thus, it has the potential to...

## Key facts

- **NIH application ID:** 10080697
- **Project number:** 5R37AG032982-10
- **Recipient organization:** HEBREW REHABILITATION CENTER FOR AGED
- **Principal Investigator:** SUSAN L MITCHELL
- **Activity code:** R37 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $172,300
- **Award type:** 5
- **Project period:** 2009-09-01 → 2022-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10080697

## Citation

> US National Institutes of Health, RePORTER application 10080697, Trial to Reduce Antimicrobial Use in Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) (5R37AG032982-10). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10080697. Licensed CC0.

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