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

Elise Crayton,Niall Anderson,Sunny Liu,Chris Fuller,Susan Michie,Fabiana Lorencatto,Laura Shallcross,Andrew Hayward,Gillian Forbes,Michelle Richardson,Catherine Smith

doi:10.1186/s12877-020-01564-1

Elise Crayton, Niall Anderson + Show 9 more

Open Access

https://doi.org/10.1186/s12877-020-01564-1

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Abstract

BackgroundOveruse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. In long-term care facilities, levels of inappropriate prescribing are as high as 75%. Numerous interventions targeting long-term care facilities’ antimicrobial stewardship have been reported with varying, and largely unexplained, effects. Therefore, this review aimed to apply behavioural science frameworks to specify the component behaviour change techniques of stewardship interventions in long-term care facilities and identify those components associated with improved outcomes.MethodA systematic review (CRD42018103803) was conducted through electronic database searches. Two behavioural science frameworks, the Behaviour Change Wheel and Behaviour Change Technique Taxonomy were used to classify intervention descriptions into intervention types and component behaviour change techniques used. Study design and outcome heterogeneity prevented meta-analysis and meta-regression. Interventions were categorised as ‘very promising’ (all outcomes statistically significant), ‘quite promising’ (some outcomes statistically significant), or ‘not promising’ (no outcomes statistically significant). ‘Promise ratios’ (PR) were calculated for identified intervention types and behaviour change techniques by dividing the number of (very or quite) promising interventions featuring the intervention type or behaviour change technique by the number of interventions featuring the intervention type or behaviour change technique that were not promising. Promising intervention types and behaviour change techniques were defined as those with a PR ≥ 2.ResultsTwenty studies (of19 interventions) were included. Seven interventions (37%) were ‘very promising’, eight ‘quite promising’ (42%) and four ‘not promising’ (21%). Most promising intervention types were ‘persuasion’ (n = 12; promise ratio (PR) = 5.0), ‘enablement’ (n = 16; PR = 4.33) and ‘education’ (n = 19; PR = 3.75). Most promising behaviour change techniques were ‘feedback on behaviour’ (n = 9; PR = 8.0) and ‘restructuring the social environment’ (e.g. staff role changes; n = 8; PR = 7.0).ConclusionSystematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks. Incorporating environmental restructuring and performance feedback may be promising intervention strategies for antimicrobial stewardship interventions within long-term care facilities.

Highlights

Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat
Systematic identification of the active ingredients of antimicrobial stewardship in long-term care facilities was facilitated through the application of behavioural science frameworks
As metaregression was not feasible, we were not able to isolate the specific contribution of each intervention type or Behaviour Change Technique (BCT) to intervention effectiveness, nor could we examine the contribution of combinations of intervention types and BCTs to effectiveness

Summary

Introduction

Overuse of antibiotics has contributed to antimicrobial resistance; a growing public health threat. Long-term care facility (LTCF) residents have an increased risk of acquiring infections and of experiencing more severe disease course and outcomes [1]. Among the most commonly reported infections that can cause outbreaks are: chest infections, gastrointestinal infections, urinary tract infections and skin and soft tissue infections [3, 4]. Infections, such as these, are associated with high morbidity and mortality rates, rehospitalisation and substantial health care costs [5,6,7]. Owing to the frequency of symptoms (e.g. fever, nausea, cough, aches, diarrhoea) that may indicate infection, antimicrobials are often prescribed to residents of LTCFs and may not always be needed (e.g. prescribed for a non-bacterial infection)

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