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Table 1 Study characteristics and intervention effects

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

First author/ Country

Design

[sample sizea]

Measurement method of behaviour

Antibiotics Assessed

Comparison/ control

Behavioural outcomes

Reported statistics

95% CI

Intervention promise

Risk of Bias

Monette 2007/ Canada [55]

cRCT

[8 LTCFs]

Not reported

Not reported

Usual care

Adherence to guidelines post-intervention 1(3-month period)

OR = 0,47

0.21, 1.05

Very

Unclear

Adherence to guidelines post-intervention 2 (3-month period)

OR = 0.36

0.18, 0.73

Adherence to guidelines follow up (3-month period)

OR = 0.48

0.23, 1.02

Naughton 2001/ US [56]

RCT

[10 LTCFs]

Form completion

Not reported

Pre-intervention

Antibiotic use consistent with guideline

OR = NR

NR

Not

Low

Jump 2013/ US [57]

Clinical Demonstration Project

[1 LTCF]

Chart review

Not reported

None

Relationship between referral source (LTCF or ID consultation service) and likelihood of needing an intervention (stewardship behaviour) [adjusted OR]

OR = 0.4

0.19, 0.78

Very

Critical

McMaughan 2016/ US [58]

Pre-post test with comparison

[12 LTCFs]

Chart review

Not reported

Comparison-no description provided

Relationship between group allocation and prescription being written: High intensity decision aid training

OR = 0.77

0.32, 1.86

Not

Serious

Relationship between group allocation and prescription being written: Low intensity decision aid training

OR = 1.19

0.47, 3.01

Pre/post intervention comparison: high intensity decision aid training

OR = 0.79

0.33, 1.88

Pre/post intervention comparison: Low intensity decision aid training

OR = 0.63

0.25, 1.60

Van Buul 2015/ Netherlands [59]

Quasi-experimental

[10 LTCFs]

Form completion

Not reported

Comparison-no description provided

Overall appropriateness of antibiotic prescribing

OR = 0.76

0.43, 1.34

Not

Serious

Appropriateness of antibiotic prescribing for UTI

OR = 0.74

0.39, 1.40

Appropriateness of antibiotic prescribing for RTI

OR = 0.95

0.39, 2.33

Petterson 2011/ Sweden [60]

cRCT

[46 LTCFs]

Survey/ questionnaire

Quinolones

Nitrofurantoin

Comparison-no description provided

Proportion of quinolones prescribed for lower UTI

Β = 0.028

− 0.193, 0.249

Quite

High

Proportion of antibiotics prescribed

Β = 0.124

− 0.228, − 0.019

Proportion of nitrofurantoin prescribed for lower UTI

Β = −  0.077

−0.242, 0.088

Schwartz 2007/ US [61]

Quasi-experimental

[1 LTCF]

Chart review

Not reported

None

Effect of intervention on incidence of antimicrobial days

Β = −0.04

NR

Very

Moderate

Effect of intervention on incidence of antimicrobial starts

Β = −0.05

NR

Loeb 2005/ Canada & US [23]

cRCT

[20 LTCFs]

Form completion

Not reported

Usual care

Rate of antimicrobial use for suspected UTI

t = − 0.49

−0.93, − 0.06

Quite

High

Total antimicrobial use between the intervention and usual care groups

t = − 0.37

−1.17, 0.44

Kassett 2016/ Canada [62]

Pre-post test

[1 LTCF]

Medical record review

Amikacin

Amoxicillin

Amoxicillin– clavulanic acid

Ampicillin

Ceftriaxone

Ciprofloxacin

Gentamicin

Levofloxacin

Meropenem

Nitrofurantoin

Norfloxacin

Piperacillin and tazobactam

Tobramycin

Trimethoprim (TMP)

Trimethoprim–sulfamethoxazole (TMP-SMX)

None

UTI rate (an index of overall antibiotic use)

t = 1.255

d = 0.535

−0.003, 0.013

Quite

Serious

Prescribed days of therapy

t = 2.293

d = 0.978

0.003, 0.066

Actual days of therapy

t = 2.902

d = 1.237

0.011, 0.065

Ciprofloxacin rate (number of ciprofloxacin prescriptions in a given month per LTCF unit occupancy for that month)

t = 3.79

d = 1.616

0.003, 0.012

Ciprofloxacin proportion (number of ciprofloxacin prescriptions in a given month per UTI case)

t = 3.809

d = 1.624

0.064, 0.216

Doernberg 2015/ US [63]

Quasi-experimental

[3 LTCFs]

Chart review

Fluoroquinolones

Nitrofurantoin Trimethoprimsulfamethoxazole

Cephalexin

Amoxicillin +/− clavulanate

None

Antibiotic starts for UTI (per 1000 resident-days)

IRR = 0.94

0.92, 0.97

Very

Serious

All antibiotic starts (per 1000 resident-days)

IRR = 0.95

0.92, 0.98

Zimmerman 2014/ US [64]

Quasi-experimental

[12 LTCFs]

Infection control log review

Not reported

Comparison-no description provided

Overall intervention effectiveness

IRR = 0.71

0.56, 0.90

Very

Moderate

Antibiotic prescribing (prescriptions per resident-day) [adjusted model]

IRR = 0.86

0.79, 0.95

Fleet 2014/ UK [65]

cRCT (pilot)

[30 LTCFs]

Not reported

Amoxicillin

Co-amoxiclav

Flucloxacillin

Trimethoprim

Clarithromycin

Cefalexin

Erythromycin

Nitrofurantoin

Ciprofloxacin

Doxycycline

Other

Control- no description provided

Pre- and post-intervention point prevalence of systemic antibiotic prescribing (per 100 residents) for treatment of infection - Intervention Group

EPR = 1.01

0.81, 1.25

Quite

Low

Pre- and post-intervention point prevalence of systemic antibiotic prescribing (per 100 residents) for treatment of infection - Control Group

EPR = 1.11

0.87, 1.41

Total antibiotic consumption (defined daily does (DDDs)/1000 residents/day (DRD))

- Intervention group

% decrease = 4.9% (3.25 DRD)

1.0, 8.6%

Total antibiotic consumption (defined daily does (DDDs)/1000 residents/day (DRD)) - Control group

% increase = 5.1% (2.24 DRD)

0.2, 10.2%

Furuno 2014/ US [66]

Pre-post test

[1 LTCF]

Semi-structured interview and chart review

Aminoglycosides

Carbapenems

Cephalosporins

Fluoroquinolones

Vancomycin

Trimethoprim-sulfamethoxazole

Tetracyclines

Nitrofurantonin

Metronidazole

Other

None

Appropriate empirical antibiotic prescribing

% Increase: 32 to 45%

NR

Not

Serious

Gugkaeva 2012/ US [67]

Phase 1 observational

Phase 2 interventional

[1 LTCF]

Medical record review

Not reported

None

Cases where antibiotics were prescribed inappropriately (comparison pre and post intervention implementation)

% Decrease: 40 to 21%

NR

Quite

Serious

Hutt 2006/ US [68]

Pre-post test

[2 LTCFs]

Nursing home record review:

- A modified Barthel Index

-Cognitive Performance Scale

-NHAP Severity Index

-Measures of intervention dose

Not reported

Control- no description provided

Compliance to guideline: Timely antibiotics - Intervention Group [change in percentage points]

−9

NR

Quite

Serious

Compliance to guideline: Timely antibiotics - Control Group [change in percentage points]

−53

NR

Compliance to guideline: Appropriate antibiotics - Intervention Group [change in percentage points]

18

NR

Compliance to guideline: Appropriate antibiotics - Control Group [change in percentage points]

−13

NR

Average total compliance to guidelines score – intervention group [change in percentage points]

5

NR

Average total compliance to guidelines score – intervention group [change in percentage points]

−5

NR

Linnebur 2011/ US [54]

Quasi-experimental

[16 LTCFs]

Medical record review

Levofloxacin

Azithromycin

Other

Control-no description provided

Providing antibiotics within 4 h - Intervention group [change in % from baseline to 2 years]

57 to 75%

NR

Quite

Critical

Providing antibiotics within 4 h - Control group [change in % from baseline to 2 years]

38 to 31%

NR

Adherence to optimal antibiotic use - Intervention group [change in % from baseline to 2 years]

60 to 66%

NR

Adherence to optimal antibiotic use - Control group [change in % from baseline to 2 years]

32 to 39%

NR

Receipt of antibiotics for 10 to 14 days - Intervention group [change in % from baseline to 2 years]

27 to 13%

NR

Receipt of antibiotics for 10 to 14 days - Control group [change in % from baseline to 2 years]

24 to 19%

NR

Rahme 2016/ US [69]

Pre-post test

[1 LTCF]

Form completion (inventory usage reports)

Fluoroquinolone

Nitrofurantoin

Ciprofloxacin

Levofloxacin

Moxifloxacin Penicillin Cephalosporin

Macrolide Tetracycline Sulfonamide

None

Total antibiotic use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−11.68%

−0.44, −18.97

Quite

Low

Penicillin use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

+  10.23%

−5.15, 1.21

Cephalosporins use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−24.49%

−0.15, 6.41

Macrolides use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−25.63%

−1.25, 4.50

Tetracyclines use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−14.29%

−3.10, 9.48

Fluoroquinolones use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−16.20%

−2.38, 6.78

Sulfonamides use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

+  9.45%

−2.02, 0.30

Nitrofurantoin use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−25.34%

−0.34, 1.33

Ciprofloxacin use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−38.7%

0.58, 4.9

Levofloxacin use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

+  9.09%

−3.21, 2.09

Moxifloxacin use (daily defined dose (DDD) per 1000 resident days (RD) [pre/post intervention percentage change]

−5.88%

−0.32, 0.34

Smith 2016/ US [70]

Pre-post test

[1 LTCF]

Chart review

Vancomycin

None

Compliance with vancomycin level monitoring

% Increase: 71–85%

NR

Quite

Low

Vancomycin trough levels in therapeutic range

% Increase: 63.3–70.5%

NR

Hutt 2011/ US [53]

Quasi-experimental

[16 LTCFs]

Chart review

Not reported

Control- no description provided

Year 1

Adherence to guideline for treating stable residents in the NH

M = 95 [approx.]

NR

Quite

Serious

Year 2

Adherence to guideline for treating stable residents in the NH

M = 98 [approx..]

NR

Zabarsky 2008/ US [71]

Quasi-experimental

[1 LTCF]

Not reported

Not reported

None

3 months Pre-intervention: rate of asymptomatic bacteria treated [per 1000 patient-days]

IRR = 1.7

1.1, 2.6

Very

Moderate

6 months Post-intervention: rate of asymptomatic bacteria treated [per 1000 patient-days]

IRR = 0.6

0.4, 1.0

7 to 30 months Post-intervention: rate of asymptomatic bacteria treated [per 1000 patient-days]

IRR = 0.3

0.2, 0.4

3 months Pre-intervention: total antimicrobial days of therapy [per 1000 patient-days]

167.7

NR

6 months Post-intervention: total antimicrobial days of therapy [per 1000 patient-days]

117.4

NR

7 to 30 Months post-intervention" total antimicrobial days of therapy [per 1000 patient-days]

109.0

NR

  1. IRR Incidence rate ratios; d-Cohen’s d effect size, OR Odds ratio, M Mean, EPR Estimated prevalence rate, t t-test statistic; −Beta coefficient, UTI Urinary tract infection, NR Not reported, CI confidence interval
  2. aSample size reports upon the sample included in the analysis only