Antimicrobial Stewardship Programs in Long‐Term Care Settings: A Meta‐Analysis and Systematic Review

Abstract

BACKGROUND Antimicrobial stewardship programs have been established in hospitals, but less studied in long‐term care facilities (LTCFs), a setting with unique challenges related to patient populations and available resources. This systematic review sought to provide a comprehensive assessment of antimicrobial stewardship interventions implemented in LTCFs, using meta‐analysis to examine their impact on overall antimicrobial use. METHODS Electronic searches of MEDLINE, Embase, and CINAHL (1990 to July 2018) identified any antimicrobial stewardship interventions in LTCFs, with no restriction on patient population, study design, or outcomes. Intervention components were categorized using the Cochrane Effective Practice and Organization of Care taxonomy on implementation strategies. Random‐effects meta‐analysis used ratio of means to facilitate pooling of different metrics of antimicrobial use. RESULTS Eighteen studies (one randomized controlled trial [RCT], four cluster RCTs, four controlled pre/post studies, and nine uncontrolled pre/post studies) met inclusion, using 13 different antimicrobial stewardship intervention strategies; 15 studies used multifaceted (maximum, seven; median, four) interventions. The three most commonly implemented strategies were educational materials, educational meetings, and guideline implementation. Intervention labor intensity and resource requirements varied considerably among interventions. Meta‐analysis of 11 studies demonstrated that antimicrobial stewardship strategies were associated with a 14% reduction in overall antimicrobial use (95% confidence interval = −8% to −20%; P < .0001), with similar results by study design but high heterogeneity (I2 = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I2 = 0%) for the cluster RCT and controlled pre/post study subgroups. Funnel plot analysis suggested publication bias, with a lack of publication of smaller studies showing increased antibiotic use. CONCLUSION Antimicrobial stewardship strategies implemented in long‐term care vary considerably in design and resource intensity, but collectively suggest potential to reduce antimicrobial use in this challenging setting. J Am Geriatr Soc 67:392–399, 2019.

Evaluating and prioritizing antimicrobial stewardship programs for nursing homes: A modified Delphi panel

“…Findings from a meta-analysis and systematic review of ASPs in nursing homes 40 are consistent with our results. They highlight some critical necessities of successful ASP implementation, particularly the importance of behavior change.…”

“…This finding is consistent with literature describing the ineffectiveness of solely educational interventions. 40 Participants consequently considered the need for multifaceted interventions, or bundling several interventions together, to provide meaningful prescribing changes. Multifaceted interventions were included in the first round of the survey, and although the intervention received favorable scores, the intervention was eliminated from the second round of the survey due to consensus regarding its lack of feasibility in nursing homes.…”

“…Our evaluation is among the few to examine and prioritize a number of interventions for improving antibiotic utilization in nursing homes. 21,26,40,41 As noted, nursing home settings are suitable candidates for ASP implementation; however, research evaluating individual interventions is limited and inconsistent, and research targeting the selection and initial implementation of ASPs is inadequate.…”

Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey

“…54,56,57 Differences in the implementation rates of ASP policies might reflect variations in resource intensiveness, or NHs may have begun incrementally building their ASPs starting with policies for which resources were more readily accessible such as tracking antibiotics use. 58 Rates of NHs that gave feedback on prescriptions to providers was very different between comprehensive ASPs and not comprehensive ASPs, and a systematic review has found that this practice can increase the effects of antibiotic stewardship interventions. 59 Additionally, comparatively few NHs with not comprehensive ASPs provided educational materials on improving antibiotic use.…”

Interventions to improve appropriate antibiotic prescribing in long-term care facilities: a systematic review

“…The present study aimed to build upon and update the existing systematic reviews of antimicrobial stewardship programmes in LTCFs [32][33][34][35][36] by applying these behavioural science frameworks to specify the components of existing interventions in this context, as a basis for identifying those that are associated with improved outcomes. The specific research questions were:…”