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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