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 con-sumption 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. In-terventions 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 I-2 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, I-2 = 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, I-2 = 17%) and a mean difference of -0.02 deaths per 1000 resident-days (95% CI-0.14 to 0.09, I-2 = 0%). Only two studies included infections as a study outcome. Conclusions: ASPs appear to improve antimicrobial use in this setting without increasing hospital ad -missions 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. (C) 2021 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.