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 |