Review
Introduction
Methods
Results
Reference, country | Study design | Interventions | Outcomes |
---|---|---|---|
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 |
References, infection | Design | Interventions | Outcomes |
---|---|---|---|
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. |