Are antimicrobial stewardship interventions effective and safe in long-term care facilities? A systematic review and meta-analysis

Background Long-term care facilities (LTCFs) are health-care settings with high antimicrobial consumption and hence need to develop effective antimicrobial stewardship programmes (ASPs). Objective To assess the effects of ASPs on care-related, clinical and ecological outcomes in LTCFs. Methods Data sources were PubMed, EMBASE, CINAHL and SCOPUS. Study eligibility criteria were original research articles (controlled clinical trials or controlled before and after studies) published up to 1 October 2020. Participants were adult residents of LTCFs, residential aged-care facilities, nursing homes, veterans' homes, skilled nursing facilities and assisted living facilities for older people. Interventions included ASPs versus standard care. Outcomes assessed were antimicrobial consumption and appropriateness, infections, hospital admissions and mortality. Available data were pooled in a meta-analysis, and inconsistency between studies was evaluated using the I2 statistic. Certainty of evidence was assessed using the GRADE approach. Results Of the 3111 papers identified, 12 studies met the inclusion criteria. All of them analysed the impact of interventions on antimicrobial use based on consumption-related variables (n = 8) and/or percentage of inappropriate prescriptions (n = 6). Pooled data showed a mean difference of –0.47 prescriptions per 1000 resident-days in favour of ASPs (95% CI –0.87 to –0.07, I2 = 71%). Five studies analysed the clinical effect of ASPs on the number of hospital admissions and/or resident mortality. The meta-analysis showed a mean difference of 0.17 hospital admissions per 1000 resident-days (95% CI –0.07 to 0.41, I2 = 17%) and a mean difference of –0.02 deaths per 1000 resident-days (95% CI –0.14 to 0.09, I2 = 0%). Only two studies included infections as a study outcome. Conclusions ASPs appear to improve antimicrobial use in this setting without increasing hospital admissions or deaths, indicating that these programmes do not lead to under-treatment of infections. Nonetheless, further higher-quality clinical trials are required to understand the effects of ASPs in LTCFs. PROSPERO registration number CRD42021225127.