Table 2 Outcomes of antimicrobial stewardship programs focusing on a single infection in long term care facilities (LTCF)

Pneumonia

Naughton, 2001 [10] US

Randomized, controlled; 10 LTF

1. Small group consensus process for guideline development with physician/nurse practitioners.

1. No differences in antimicrobial use consistent with guidelines between two randomized groups.

Facilities randomized to physician/nurse practitioner intervention only, or multidisciplinary (registered nurses/LPN’s).

2. In a pre/post analysis:

a) Pre/post parenteral antibiotics meeting guidelines 50% vs 81.8% (p = 0.06) for multi-disciplinary group and 65% vs 69% (p = 0.73) for physician/practitioners.

2. Nurses: 1 hour training session on guidelines.

3. Laminated pocket cards summarizing guidelines.

b) No change in 30 day mortality or hospitalization.

4. Laminated posters with guidelines by telephone.

Linnebur, 2011 [11] US

Non-randomized: 8 intervention homes, 8 control homes.

1. Optimized immunization, diagnostic testing at facility level.

1. Optimal antibiotic use pre/post: intervention 60% vs 66%; control 32% vs 39% (NS).

2. Interactive educational sessions for NH staff to improve vaccination rates and nursing assessment skills.

2. Duration of antibiotics, no difference.

3. Antibiotics within 4 hours: 57% → 75% vs 38% → 31% (p < 0.001)

3. Study liaison nurse to facilitate change.

4. Academic detailing to physicians

Urinary tract infection

Loeb, 2005 [12] Canada

Cluster randomized: 24 NH

1. Diagnostic & treatment algorithm for urinary infection.

1. Antimicrobial courses for suspected urinary infection: 1.17 vs 1.59/1,000 resident days– difference - 0.49 (−0.93, -0.06)

2. Small group interactive sessions for nurses using case scenarios - video-tapes of sessions, written material, continuing outreach visits.

2. Total antimicrobial use: 3.52 vs 3.93/1,000 days difference −0.37 (−1.17, 0.44)

3. One on one interviews with physicians.

4. Pocket cards and posters with algorithms.

Zabarsky, 2008 [13] US

Pre/post: single LTCF

1. Education of nursing staff to discourage urine cultures in absence of symptoms. Pocket cards with criteria for cultures.

In 6 months after intervention:

1. Inappropriate urine cultures: 2.6 → 0.9/1000 (p < 0.04)

2. Treatment of ASB: 167.1 → 117.4/1000 pt-days (p = 0.0017)

3. Total antimicrobial days: 167.7 → 117.4/1,000 pt days (p < 0.001) Reductions maintained for 7 to 30 months while intervention continued.

2. Education of physicians/nurse practitioners re current guidelines not to treat ASB and adverse effects of antibiotics. Pocket cards for diagnosis and treatment of symptomatic urinary infection.

3. Posters at computer stations used by nurses/primary care physicians.

4. Follow-up educational sessions semi-annually by infection control nurse with case based feedback of inappropriate practices.

Rummukainen, 2012 [14] Finland

Pre/post; 25 primary care hospitals, 39 NH

1. Visit of team to facility with education: structured interview of individual patients, review of systemic antimicrobials, diagnostic practices for UTI.

Proportion of patients receiving antibiotic prophylaxis for UTI: 13% in 2005 → 6% in 2008 (p < 0.001)

2. Regional guidelines developed and published.

3. Annual questionnaire to reinforce guideline consistent use of antibiotics.