Table 2.
Types, areas, and outcomes of AMS strategies in the RACF
| Authors (country, year, study size) | Types of interventions | Areas targeted | Study outcomes | Study limitations |
|---|---|---|---|---|
| Naughton et al129 (US, 2001, ten RACFs) | Multifaceted education intervention involving physicians, nurse practitioners, and nursing staff | Consensus antibiotic treatment guidelines for nursing home-acquired pneumonia | Significant increase in the use of parenteral antibiotics in accordance with guidelines, but did not alter oral antibiotic use, hospitalization, or 30-day mortality. | Sample size was too small to determine the impact of the intervention on hospitalization and mortality. |
| Loeb et al130 (Canada and US, 2005, 24 RACFs) | Multifaceted approach targeting nurses, and interviews with physicians | Diagnostic and treatment algorithm for UTIs | Rates of antimicrobial use for suspected UTI was significantly lower in the intervention than usual care group. | No significant difference found in total antimicrobial use (when accounting for other infections). The effect of the intervention reduced over time. |
| Hutt et al131 (US, 2006, two RACFs) | Multifaceted approach involving institutional-level change of antibiotic policy, and educational sessions for nurses and physicians | Evidence-based guidelines for treating nursing home-acquired pneumonia | The compliance with the guidelines improved, including the use of appropriate antibiotics, and timely antibiotic initiation at the intervention facility. | The intervention was brief (over one influenza season) and limited to one intervention facility. |
| Schwartz et al132(US, 2007, single RACF) | National guidelines, hospital resistance data, and physician feedback were incorporated into a series of four teaching sessions and into booklets | Optimal treatment for common long-term care infection syndromes | Antimicrobial use decreased significantly during the intervention period; both decreases were sustained during the 2-year postintervention period. | The intervention was tailored specifically for hospital-based RACF with on-site pathology and radiology supports. |
| Monette et al133 (Canada, 2007, eight RACFs) | Educational intervention comprising of mailing an antibiotic guide to physicians with individual antibiotic prescribing profiles in previous 3 months | Targeted infections were UTIs, RTIs, SSTIs, and septicemia of unknown origin | Nonadherent antibiotic prescriptions decreased by 20.5% in the experimental group, compared with 5.1% in the control group. | Did not address the effect of clustering on the sample size, which undermines the ability to adequately detect changes in the outcome measures. |
| Zabarsky et al134 (US, 2008, single RACF) | Education of nursing staff and primary care practitioners by the infection control nurse | Optimal management of asymptomatic bacteriuria | Inappropriate submission of urine cultures, overall rate of treatment of asymptomatic bacteriuria, and total antimicrobial days of therapy were reduced significantly. | Study was carried out in a single RACF with availability of full-time primary care practitioners, thus the result may not be applicable to RACF without this support. |
| Pettersson et al135 (Swedan, 2011, 58 RACFs) | Small educational group sessions with nurses and physicians | Guidelines for management of lower UTI, targeted at reducing use of quinolones | Modest effect shown; proportion of quinolones decreased significantly in both intervention and control groups, but no difference found between the two groups. | The intervention had a modest effect. The reduction in proportion of quinolones cannot be attributed to the intervention. |
| Linnebur et al136 (US, 2011, 16 RACFs) | Educational sessions for nurses and academic detailing to general practitioners by pharmacists | National NHAP treatment guidelines | Increased adherence to guidelines about timely administration of antibiotics to NHAP episodes, but not adherence regarding the optimal duration and selection of antibiotic. | Effect of an intervention toward antibiotic choice and length of therapy was not seen, largely due to insufficient time allocated for academic detailing and limited interaction with the prescribers. |
| Gugkaeva and Franson137 (US, 2012, single RACF) | A pharmacist-led AMS program consists of a prospective audit and interventions, with onsite pharmacist support | Optimal treatment for common long-term care infection syndromes | Significant reduction in inappropriate prescribing of antibiotics was seen within the first 3 months after implementation with good acceptance by prescribers. | The study was limited to a single RACF, and the sustainability of this intervention (ie, a 3-month trial) was not assessed. |
| Jump et al138 (US, 2012, single RACF) | Infectious disease consultation service that provides on-site consultations to residents; the service team consisted of an infectious disease physician and a nurse practitioner | Optimal treatment for common long-term care infection syndromes | Total systemic antibiotic (both oral and intravenous) administration decreased significantly by 30%. The rate of positive C. difficile tests declined after the intervention. | This model is labor-intensive and may not be applicable to RACF without sufficient infectious disease supports. |
Abbreviations: AMS, antimicrobial stewardship; RACF, residential aged care facilities; UTI, urinary tract infection; RTI, respiratory tract infection; SSTI, skin and soft tissue infection; NHAP, nursing home-acquired pneumonia.