Assessment of implementation strategies adopted for antimicrobial stewardship interventions in long-term care facilities: a systematic review

BACKGROUND:The implementation of antimicrobial stewardship (AMS) interventions in long-term care facilities (LTCFs) is influenced by multi-level factors (resident, organizational, and external) making their effectiveness sensitive to the implementation context. OBJECTIVES:This study assessed the strategies adopted for the implementation of AMS interventions in LTCFs, whether they considered organizational characteristics, and their effectiveness. DATA SOURCES:Electronic databases until April 2022. STUDY ELIGIBILITY CRITERIA:Articles covering implementation of AMS interventions in LTCFs. ASSESSMENT OF RISK OF BIAS:Mixed Methods Appraisal Tool for empirical studies. METHODS OF DATA SYNTHESIS:Data were collected on AMS interventions and context characteristics (e.g. type of facility, staffing, and residents). Implementation strategies and outcomes were mapped according to the Expert Recommendations for Implementing Change (ERIC) framework and validated taxonomy for implementation outcomes. Implementation and clinical effectiveness were assessed according to the primary and secondary outcomes results provided in each study. RESULTS:Among 48 studies included in the analysis, 19 (40%) used implementation strategies corresponding to one to three ERIC domains, including education and training (n = 36/48, 75%), evaluative and iterative strategies (n = 24/48, 50%), and support clinicians (n = 23/48, 48%). Only 8/48 (17%) studies made use of implementation theories, frameworks, or models. Fidelity and sustainability were reported respectively in 21 (70%) and 3 (10%) of 27 studies providing implementation outcomes. Implementation strategy was considered effective in 11/27 (41%) studies, mainly including actions to improve use (n = 6/11, 54%) and education (n = 4/11, 36%). Of the 42 interventions, 18/42 (43%) were deemed clinically effective. Among 21 clinically effective studies, implementation was deemed effective in four and partially effective in five. Two studies were clinically effective despite having non-effective implementation. CONCLUSIONS:The effectiveness of AMS interventions in LTCFs largely differed according to the interventions' content and implementation strategies adopted. Implementation frameworks should be considered to adapt and tailor interventions and strategies to the local context.