Table 1 Reports evaluating the implementation of comprehensive antimicrobial stewardship programs for long term care facilities (LTCF)

Schwartz et al., 2007 [6] US

Prospective, before/after; single centre, hospital-based LTC wards; on-site ID consultation.

1. Four teaching sessions over 18 months including all 20 full time staff internists; groups of 3–7.

Pre/post analysis of 100 random charts pre intervention and during 5 months after the last session:

2. Published guidelines on LTC infections and results of local audit discussed; interactive discussion of local cases.

1. Antimicrobial courses met guideline for diagnostic criteria: 32% vs 62%, p = 0.006

3. Evidence-based algorithms and guidelines developed with internists.

2. Initial antimicrobial therapy met guidelines: 11% vs 39%; p < 0.001

4. Pocket booklet with optimal management of LTC infection syndromes.

3. Antimicrobial days fell 29.7%, starts fell 25.9% - improvements sustained 2 yr post-intervention

Monette et al., 2007 [7] Canada

Cluster, randomized controlled trial; 8 LTC, Montreal

Interventions for experimental group:

Experimental vs control homes at trial end:

1. Mailing antibiotic guide and individual prescribing profile past 3 months to 36 physicians. Antibiotic courses given by physician characterized as adherent or non-adherent.

1. Nonadherent prescriptions: 20.5% vs 5.1%

2. Likelihood of prescription of nonadherent antibiotics:

→post-intervention one: OR 0.47, (95% CI 0.21-1.0 1.05)

2. Repeat second mailing 4 months later.

→post-intervention two: OR 0.36 (0.18, 0.73)

→15 months follow-up: OR 0.48 (0.23-1.02)

Pettersson et al., 2011 [8] Sweden

Cluster, randomized controlled trial; 58 NH

1. Local physician, nurse, developed guidelines in focus groups. Evaluation of guidelines in pilot study with revision.

Effect of intervention (95% CI) at 2 years (differences):

Primary outcome:

Fluoroquinolones for UTI: 0.028 (−0.193, 0.249)

2. Small educational sessions – physicians, nurses.

Secondary outcomes:

UTIs/resident: 0.04 (−0.01, 0.09)

3. Feedback on prescribing & references to available guidelines; discussion of structural, organizational, social barriers to change.

All infections:

antibiotics −0.12 (−0.23, -0.02)

“wait & see” 0.143 (0.047, 0.240)

Nitrofurantoin for lower UTI in women: - 0.077 (−0.247, 0.088)

Jump et al., 2012 [9] US

Pre/post; single site with dedicated physician/nurse practitioner care on 4 LTCF wards.

ID consultation service team (ID physician and nurse practitioner) once weekly on site and available by phone contact 24/7.

36 months pre compared with 18 months post: Reduction in

→total antibiotics, 30.1%, p < 0.001

→oral antibiotics, 31.6%, p,0.001

→intravenous antibiotics, 25%, p = 0.001

Positive C. difficile/1,000 days decreased: time series, p = 0.04