Interventions to Improve Antimicrobial Stewardship for Older People in Care Homes: A Systematic Review
Inappropriate antimicrobial prescribing has been reported in care homes. This may result in serious drug-related adverse events, Clostridium difficile colonization, and the development of antimicrobial resistance among care home residents. Interventions to improve antibiotic prescribing in nursing homes have been reported through clinical trials, but whether antifungal and antiviral prescribing and residential homes have been considered, or how outcomes were measured and reported in such interventions, remains unclear.
Our aims were to evaluate the effect of interventions to improve antimicrobial stewardship in care homes and to report the outcomes used in these trials.
We searched 11 electronic databases and five trial registries for studies published until 30 November 2018. Inclusion criteria for the review were randomized controlled trials, targeting care home residents and healthcare professionals, providing interventions to improve antimicrobial prescribing compared with usual care or other interventions. The Cochrane tools for assessing risk of bias were used for quality assessment. A narrative approach was taken because of heterogeneity across the studies.
Five studies met the inclusion criteria. The studies varied in terms of types of infection, key targets, delivery of interventions, and reported outcomes. In total, 27 outcomes were reported across the studies, with seven not prespecified in the methods. The interventions had little impact on adherence to guidelines and prevalence of antimicrobial prescribing; they appeared to decrease total antimicrobial consumption but were unlikely to have affected overall hospital admissions and mortality. The overall quality of evidence was low because the risk of bias was high across the studies.
The interventions had limited effect on improving antimicrobial prescribing but did not appear to cause harm to care home residents. The low quality of evidence and heterogeneity in outcome measurement suggest the need for future well-designed studies and the development of a core outcome set to best evaluate the effectiveness of antimicrobial stewardship in care homes.
The authors thank Ms. Angela Thompson (Queen’s University Belfast) for her assistance with developing the search strategy and Dr. Audrey Rankin (Queen’s University Belfast) for her advice on the content of data extraction sheets.
Compliance with Ethical Standards
As this was a systematic review, ethical approval to conduct the study was not required.
Conflict of interest
Hoa Nguyen, Michael Tunney, and Carmel Hughes have no conflicts of interest that are directly relevant to the content of this article.
Hoa Nguyen is supported by a PhD research scholarship from the Vietnam International Education Cooperation Development in Vietnam. The funder played no role in the design, analysis, or conduct of the study.
- 1.United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing; 2015. http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2015_Report.pdf. Accessed 31 Aug 2018.
- 3.European Centre for Disease Prevention and Control. Point prevalence survey of healthcare-associated infections and antimicrobial use in European long-term care facilities. April–May 2013. Stockholm; 2014. https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/healthcare-associated-infections-point-prevalence-survey-long-term-care-facilities-2013.pdf. Accessed 31 Aug 2018.
- 8.Lim CJ, Kong DC, Stuart RL. Reducing inappropriate antibiotic prescribing in the residential care setting: current perspectives. Clin Interv Aging. 2014;9:165–77.Google Scholar
- 13.World Health Organization. Global action plan on antimicrobial resistance; 2015. http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf. Accessed 31 Aug 2018.
- 14.World Health Organization. Antimicrobial resistance: global report on surveillance; 2014. http://apps.who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf?ua=1. Accessed 31 Aug 2018.
- 17.National Institute for Health and Care Excellence. Antimicrobial stewardship : systems and processes for effective antimicrobial medicine use, NICE guideline [NG15]; 2015. https://www.nice.org.uk/guidance/ng15/resources/antimicrobial-stewardship-systems-and-processes-for-effective-antimicrobial-medicine-use-1837273110469. Accessed 31 Aug 2018.
- 25.Nguyen H, Hughes C, Tunney M. Interventions to improve antimicrobial stewardship for older people in care homes. PROSPERO 2017 CRD42017070116; 2017. http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017070116. Accessed 31 Aug 2018.
- 26.Rodrigues R, Huber M, Lamura G, editors. Facts and figures on healthy ageing and long-term care. Vienna: European Centre for Social Welfare Policy and Research; 2012. https://www.euro.centre.org/downloads/detail/3059. Accessed 31 Aug 2018.
- 28.Higgins J, Altman D, Sterne J. Assessing risk of bias in included studies, chapter 8. In: Higgins JPT, Green S, editors. Cochrane Handb Syst Rev Interv; 2011. http://handbook-5-1.cochrane.org/. Accessed 31 Aug 2018.
- 29.Effective Practice and Organisation of Care (EPOC). Suggested risk of bias criteria for EPOC reviews. EPOC Resources for review authors. Oslo: Norwegian Knowledge Centre for the Health Services; 2016. http://epoc.cochrane.org/resources/epoc-resources-review-authors. Accessed 31 Aug 2018.
- 42.Flevari A, Theodorakopoulou M, Velegraki A, Armaganidis A, Dimopoulos G. Treatment of invasive candidiasis in the elderly: a review. Clin Interv Aging. 2013;8:1199–208.Google Scholar
- 43.Lubeek SFK, van der Geer ER, van Gelder MMHJ, Koopmans RTCM, van de Kerkhof PCM, Gerritsen MJP. Current dermatologic care in Dutch nursing homes and possible improvements: a nationwide survey. J Am Med Direct Assoc. 2015;16(8):714.e1–6. https://doi.org/10.1016/j.jamda.2015.04.015.CrossRefGoogle Scholar
- 52.Bell BG, Schellevis F, Stobberingh E, Goossens H, Pringle M. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis. 2014;14(13):1–25.Google Scholar
- 57.Llewelyn MJ, Darwin E, Tonkin-Crine S, et al. The antibiotic course has had its day. Br Dent J. 2017;223(5):337.Google Scholar
- 62.National Institute for Health and Care Excellence. Antimicrobial stewardship: prescribing antibiotics, key therapeutic topic [KTT9] [Internet]; 2015. https://www.nice.org.uk/advice/ktt9/resources/antimicrobial-stewardship-prescribing-antibiotics-1632178559941. Accessed 31 Aug 2018.
- 63.Center for Disease Dynamics, Economics and Policy. State of the world’s antibiotics, 2015. Washington, DC: CDDEP; 2015. https://www.cddep.org/wp-content/uploads/2017/06/swa_executive_summary_edits_2016.pdf. Accessed 31 Aug 2018.