Interventions to Improve Antimicrobial Stewardship for Older People in Care Homes: A Systematic Review.

Here is the structured PICO analysis for the forty-fourth article you uploaded:

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Full Title (verbatim and exact):

“Interventions to Improve Antimicrobial Stewardship for Older People in Care Homes: A Systematic Review”

Nguyen HQ, Tunney MM, Hughes CM

Drugs & Aging (2019); 36:355–369

DOI: https://doi.org/10.1007/s40266-019-00637-0

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Type of Article:

Systematic review of cluster-randomised controlled trials (c-RCTs)

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PICO Analysis:

Population:

Older adults (aged ≥65 years) living in care homes, including:
- Nursing homes, skilled nursing facilities, and long-term care facilities
- Total of 5 included c-RCTs involving settings in the USA, Canada, Sweden, and the UK
Studies also included care home staff and prescribing physicians as intervention targets

Intervention:

Multifaceted antimicrobial stewardship (AMS) interventions aiming to improve antimicrobial prescribing, which included:

Development and dissemination of antibiotic prescribing guidelines
Staff and/or physician training sessions
Feedback and audit reports
Algorithms or structured tools (e.g. RAMP, Loeb criteria)
Education on infection recognition and management

Target infections included:

Urinary tract infections (UTIs)
Pneumonia
All types of infections

Comparator:

Usual care in all five included studies
In one study, the comparison was between a physician-only intervention and a multidisciplinary (physician + nurse) intervention

Outcome:

1. Person-centred outcomes:

Not directly assessed in any of the five trials
Proxy outcomes included:
- Hospitalisation rates (reported in 3 studies)
- Mortality (reported in 1 study)
- No significant differences were observed in either outcome between intervention and control groups

2. Process outcomes:

Across 5 trials, the following AMS-related outcomes were measured:

Adherence to antimicrobial guidelines:
- Only 1 study showed a significant improvement in guideline-concordant prescribing after the second mailing of feedback and educational material to physicians
Prevalence of antimicrobial prescribing:
- One study showed significant reductions in antibiotic use for suspected UTIs
- Two others showed no significant difference in overall prescribing prevalence
Total antimicrobial consumption (measured as DDDs/1000 resident-days):
- Two studies reported reduced consumption in intervention groups
Appropriateness of prescribing:
- One study showed improved adherence to McGeer and Loeb minimum criteria for infection diagnosis and antibiotic initiation
Use of broad-spectrum antibiotics, resistance, or patient-reported outcomes were not assessed
- Duration of antibiotic therapy was also not reported in any study

3. Health system outcomes:

Hospital admissions and mortality were unchanged by the interventions
No economic or cost-effectiveness data were reported
No studies involved residents or families in AMS interventions
Risk of bias was high in all included studies, especially due to lack of blinding and loss to follow-up

Summary Conclusion:

This systematic review found that AMS interventions in care homes produced modest improvements in antimicrobial prescribing for older people, particularly in reducing antibiotic use for UTIs and improving prescribing appropriateness. However, these interventions did not reduce hospitalisation or mortality, and no studies assessed antimicrobial resistance or cost-effectiveness. Due to methodological limitations and high heterogeneity, the overall quality of evidence was low. The authors recommend the development of a core outcome set (COS) to standardise evaluation in future trials and expand the scope to include residents’ perspectives, antiviral and antifungal use, and sustainability of practice change.

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