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NIHR Signal Antimicrobial stewardship programmes reduce antibiotic use in long-term care homes

Published on 12 March 2019

doi: 10.3310/signal-000746

Antimicrobial stewardship programmes have been found to reduce antibiotic use in long-term care residences by 14% when pooling evidence across a range of study types and interventions.  

Antimicrobial resistance is a public health threat, and overuse of antimicrobials is one of the main causes. Antimicrobial stewardship programmes are a government strategy to support the appropriate prescribing of antimicrobials within the NHS. There has been little evidence for their use or effectiveness in long-term care settings.

This systematic review identified 18 studies, mostly from the US, assessing multifaceted stewardship programmes. These combine education, protocols and monitoring of guideline implementation.

The absolute effect in terms of practice change cannot be quantified. However, the studies showed broadly consistent and positive effects on reduced antimicrobial use. Studies were of mixed design and at high risk of bias. Given limited evidence in the community setting, this is nevertheless a helpful addition to the knowledge base.

Further information on the optimal strategy and method of implementation, such as tool-kits, could help address this issue better in long-term care.

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Why was this study needed?

The World Health Organisation describes antimicrobial resistance as one of the greatest threats to global health and development. Recent studies suggest that unless action is taken, resistance could be responsible for 10 million annual deaths by 2050, greater than mortality from all other causes. There is growing concern for various hospital-acquired and community infections where there are few treatment options and infections are becoming resistant to the strongest antibiotics.

A key factor in this crisis in some parts of the world is the overuse of antibiotics. Antimicrobial stewardship programmes are a central part of the UK government’s Five Year Antimicrobial Resistance Strategy to guide appropriate use.

Studies have highlighted a particular need for stewardship in long-term care facilities where over-prescribing is common, and residents are at high risk of antibiotic-related harms.

This study aimed to look at the impact of these programmes in long-term care facilities, and define the resources available to support their implementation.

What did this study do?

This systematic review included 18 papers published from 1990 to 2018 that examined implementation and outcomes from antimicrobial stewardship programmes in long-term care settings.

The studies comprised five randomised controlled trials (four cluster-randomised), four controlled and nine uncontrolled before and after studies. Most studies assessed multifaceted stewardship programmes including on average four elements, such as education, guideline implementation, changes to organisational structure, audit and feedback. Implementation varied widely from one-off sessions to extensive weekly commitments. Eleven studies looking at effects on antibiotic use were pooled in meta-analysis.   

Fourteen studies were conducted in North America, with one each from Australia, Sweden, the Netherlands and UK, potentially limiting its applicability to the UK. The authors recorded that there was the potential that studies with a positive effect were not published and therefore important data may have been missed. Risk of bias was high which may have led to an exaggerated effect.

What did it find?

  • Meta-analysis of 11 controlled trials and pre-post studies, using any intervention type, found that antimicrobial stewardship programmes reduced overall antimicrobial use by 14% (mean difference 0.86, 95% confidence interval -8% to -20%).
  • The effect was similar regardless of study design. There was wide variation in effect in uncontrolled pre-post studies, though still with mostly positive findings. Most studies looked at antimicrobial prescribing rates or appropriateness of prescribing; exclusion of two studies looking at less comparable outcomes (total number of infections treated and treatment for asymptomatic bacteria in the urine) didn’t alter the size of the effect.
  • Nine studies also assessed varied clinical outcomes such as rates of hospital admission, urinary tract infection and mortality, but these are not analysed by the review.

What does current guidance say on this issue?

The NICE 2015 guideline on antimicrobial stewardship provides a series of recommendations on stewardship programmes for commissioners and providers. These include establishing core stewardship teams and developing processes within organisations. Recommended interventions include reviewing prescribing decisions, ensuring promotion of antibiotics recommended in local or national guidelines, promoting education for health and social care practitioners and IT and decision-support systems. The accompanying quality standard includes advice on self-limiting conditions, delayed prescribing and collecting microbiological samples.

The NICE quality standard on infection control similarly recommends that prescribing should be in line with local guidance and formularies.

Public Health England provides toolkits and other resources for use in NHS hospitals as part of the government strategy to slow the growth of antimicrobial resistance.  

What are the implications?

This review provides insight into the use of antimicrobial stewardship programmes in long-term care facilities. Despite wide variation in study design and interventions, the consistent direction of effect gives encouragement that they can reduce antimicrobial overuse in this setting.  Most evidence to date has been from the acute sector, so this review adds to our knowledge although studies of mixed quality

Standardised implementation would require better understanding of the optimal strategy and individual programme components that are most effective. Resource implications may include staff education, time commitment and support from physicians, prescribing nurses and pharmacists. 

Cost and sustainability are important considerations given that long-term care facilities frequently face financial constraint. However, as the authors suggest, there may be scope for programme flexibility to reflect local needs.

Citation and Funding

Wu JH, Langford BJ, Daneman N et al. Antimicrobial stewardship programs in long-term care settings: a meta-analysis and systematic review. J Am Geriatr Soc. 2019;67(2):392-99.

No funding was attached to this study, and the authors declare no conflicts of interest.

Bibliography

Daneman N, Gruneir A, Bronskill S E et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA. 2015;175(8):1131-1339.

Mody L, Crnich C. Effects of excessive antibiotic use in nursing homes. JAMA Intern Med.2015;175(8):1339-41.

NICE. Antimicrobial stewardship. QS121. London: National Institute for Health and Care Excellence; 2016.

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Infection prevention and control. QS61. London: National Institute for Health and Care Excellence; 2014.

POST. UK trends in infectious disease. London: Parliamentary Office of Science and Technology. 2017;545:1-5.

Public Health England. Keep antibiotics working. London: Public Health England; 2018.

Public Health England. Antimicrobial stewardship: start smart – then focus. London: Public Health England; 2015.

WHO. Antibiotic resistance. Geneva: World Health Organization; 2018.

Why was this study needed?

The World Health Organisation describes antimicrobial resistance as one of the greatest threats to global health and development. Recent studies suggest that unless action is taken, resistance could be responsible for 10 million annual deaths by 2050, greater than mortality from all other causes. There is growing concern for various hospital-acquired and community infections where there are few treatment options and infections are becoming resistant to the strongest antibiotics.

A key factor in this crisis in some parts of the world is the overuse of antibiotics. Antimicrobial stewardship programmes are a central part of the UK government’s Five Year Antimicrobial Resistance Strategy to guide appropriate use.

Studies have highlighted a particular need for stewardship in long-term care facilities where over-prescribing is common, and residents are at high risk of antibiotic-related harms.

This study aimed to look at the impact of these programmes in long-term care facilities, and define the resources available to support their implementation.

What did this study do?

This systematic review included 18 papers published from 1990 to 2018 that examined implementation and outcomes from antimicrobial stewardship programmes in long-term care settings.

The studies comprised five randomised controlled trials (four cluster-randomised), four controlled and nine uncontrolled before and after studies. Most studies assessed multifaceted stewardship programmes including on average four elements, such as education, guideline implementation, changes to organisational structure, audit and feedback. Implementation varied widely from one-off sessions to extensive weekly commitments. Eleven studies looking at effects on antibiotic use were pooled in meta-analysis.   

Fourteen studies were conducted in North America, with one each from Australia, Sweden, the Netherlands and UK, potentially limiting its applicability to the UK. The authors recorded that there was the potential that studies with a positive effect were not published and therefore important data may have been missed. Risk of bias was high which may have led to an exaggerated effect.

What did it find?

  • Meta-analysis of 11 controlled trials and pre-post studies, using any intervention type, found that antimicrobial stewardship programmes reduced overall antimicrobial use by 14% (mean difference 0.86, 95% confidence interval -8% to -20%).
  • The effect was similar regardless of study design. There was wide variation in effect in uncontrolled pre-post studies, though still with mostly positive findings. Most studies looked at antimicrobial prescribing rates or appropriateness of prescribing; exclusion of two studies looking at less comparable outcomes (total number of infections treated and treatment for asymptomatic bacteria in the urine) didn’t alter the size of the effect.
  • Nine studies also assessed varied clinical outcomes such as rates of hospital admission, urinary tract infection and mortality, but these are not analysed by the review.

What does current guidance say on this issue?

The NICE 2015 guideline on antimicrobial stewardship provides a series of recommendations on stewardship programmes for commissioners and providers. These include establishing core stewardship teams and developing processes within organisations. Recommended interventions include reviewing prescribing decisions, ensuring promotion of antibiotics recommended in local or national guidelines, promoting education for health and social care practitioners and IT and decision-support systems. The accompanying quality standard includes advice on self-limiting conditions, delayed prescribing and collecting microbiological samples.

The NICE quality standard on infection control similarly recommends that prescribing should be in line with local guidance and formularies.

Public Health England provides toolkits and other resources for use in NHS hospitals as part of the government strategy to slow the growth of antimicrobial resistance.  

What are the implications?

This review provides insight into the use of antimicrobial stewardship programmes in long-term care facilities. Despite wide variation in study design and interventions, the consistent direction of effect gives encouragement that they can reduce antimicrobial overuse in this setting.  Most evidence to date has been from the acute sector, so this review adds to our knowledge although studies of mixed quality

Standardised implementation would require better understanding of the optimal strategy and individual programme components that are most effective. Resource implications may include staff education, time commitment and support from physicians, prescribing nurses and pharmacists. 

Cost and sustainability are important considerations given that long-term care facilities frequently face financial constraint. However, as the authors suggest, there may be scope for programme flexibility to reflect local needs.

Citation and Funding

Wu JH, Langford BJ, Daneman N et al. Antimicrobial stewardship programs in long-term care settings: a meta-analysis and systematic review. J Am Geriatr Soc. 2019;67(2):392-99.

No funding was attached to this study, and the authors declare no conflicts of interest.

Bibliography

Daneman N, Gruneir A, Bronskill S E et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA. 2015;175(8):1131-1339.

Mody L, Crnich C. Effects of excessive antibiotic use in nursing homes. JAMA Intern Med.2015;175(8):1339-41.

NICE. Antimicrobial stewardship. QS121. London: National Institute for Health and Care Excellence; 2016.

NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial use. NG15. London: National Institute for Health and Care Excellence; 2015.

NICE. Infection prevention and control. QS61. London: National Institute for Health and Care Excellence; 2014.

POST. UK trends in infectious disease. London: Parliamentary Office of Science and Technology. 2017;545:1-5.

Public Health England. Keep antibiotics working. London: Public Health England; 2018.

Public Health England. Antimicrobial stewardship: start smart – then focus. London: Public Health England; 2015.

WHO. Antibiotic resistance. Geneva: World Health Organization; 2018.

Antimicrobial stewardship programs in long-term care settings: a meta-analysis and systematic review

Published on 6 December 2018

Wu, J. H.,Langford, B. J.,Daneman, N.,Friedrich, J. O.,Garber, G.

J Am Geriatr Soc , 2018

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 (I(2) = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I(2) = 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.

Expert commentary

Long term care facilities account for significant antibiotic use but have weaker antibiotic stewardship and infection control than hospitals.

These authors from Canada usefully analyse 18, mostly American, studies of stewardship interventions in long term care facilities, including 11 in a meta-analysis. They found that stewardship interventions, mostly education and guidelines, achieved an average 14% reduction in antibiotic use. 

What is less clear are the effects on patient outcomes, reported in only nine of the 18 studies, and whether reductions largely reflected shorter courses or fewer prescriptions.  Nor is it certain how readily US data, often for ‘intensive’ long term care facilities translate to British care or nursing homes. These, though, are not criticisms: rather they are key pointers for further study.

David Livermore, Professor of Medical Microbiology, University of East Anglia

The commentator declares no conflicting interests