Interventions to improve antimicrobial stewardship for older people in care homes: a systematic review

Background: Inappropriate antimicrobial prescribing has been reported in care homes. This may result in serious drugrelated adverse events, Clostridium difcile 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.
Objectives: Our aims were to evaluate the efect of interventions to improve antimicrobial stewardship in care homes and to
report the outcomes used in these trials.
Methods: We searched 11 electronic databases and fve 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.
Results: 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 prespecifed
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 afected overall hospital admissions and
mortality. The overall quality of evidence was low because the risk of bias was high across the studies.
Conclusion: The interventions had limited efect 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 efectiveness of antimicrobial stewardship in care homes