Antimicrobial Stewardship Programs in Long-term Care Settings

A Meta-analysis and Systematic Review

Julie Hui-Chih Wu, MSc; Bradley J. Langford, PharmD; Nick Daneman, MD; Jan O. Friedrich, MD; Gary Garber, MD


J Am Geriatr Soc. 2019;67(2):392-399. 

In This Article

Abstract and Introduction


Background: Antimicrobial stewardship programs have been established in hospitals, but less studied in long-term care facilities (LTCFs), a setting with unique challenges related to patient populations and available resources. This systematic review sought to provide a comprehensive assessment of antimicrobial stewardship interventions implemented in LTCFs, using meta-analysis to examine their impact on overall antimicrobial use.

Methods: Electronic searches of MEDLINE, Embase, and CINAHL (1990 to July 2018) identified any antimicrobial stewardship interventions in LTCFs, with no restriction on patient population, study design, or outcomes. Intervention components were categorized using the Cochrane Effective Practice and Organization of Care taxonomy on implementation strategies. Random-effects meta-analysis used ratio of means to facilitate pooling of different metrics of antimicrobial use.

Results: Eighteen studies (one randomized controlled trial [RCT], four cluster RCTs, four controlled pre/post studies, and nine uncontrolled pre/post studies) met inclusion, using 13 different antimicrobial stewardship intervention strategies; 15 studies used multifaceted (maximum, seven; median, four) interventions. The three most commonly implemented strategies were educational materials, educational meetings, and guideline implementation. Intervention labor intensity and resource requirements varied considerably among interventions. Meta-analysis of 11 studies demonstrated that antimicrobial stewardship strategies were associated with a 14% reduction in overall antimicrobial use (95% confidence interval = −8% to −20%; P < .0001), with similar results by study design but high heterogeneity (I2 = 86%) for the uncontrolled pre/post study subgroup and no heterogeneity (I2 = 0%) for the cluster RCT and controlled pre/post study subgroups. Funnel plot analysis suggested publication bias, with a lack of publication of smaller studies showing increased antibiotic use.

Conclusion: Antimicrobial stewardship strategies implemented in long-term care vary considerably in design and resource intensity, but collectively suggest potential to reduce antimicrobial use in this challenging setting.


The emergence of antimicrobial resistance presents a serious public health threat and is propagated by inappropriate and extensive use of antimicrobials in all healthcare sectors. Residents in long-term care facilities (LTCFs) are at risk of infections, and are challenging to assess, which prompts the overuse of antibiotics in this setting. Antibiotic use is extensive, and antibiotic resistance is common, in LTCFs.[1] The prevalence of residents receiving at least one antibiotic in a single year has been reported to be between 47% and 79%.[1,2] Furthermore, as in the acute-care and primary care settings, residents in LTCFs are also vulnerable to inappropriate use, with estimated prevalence as high as 75%.[3,4] There is significant variability in antimicrobial use among various LTCFs and LTC prescribers.[2] Residents in facilities with higher antimicrobial use are more likely to experience negative outcomes, such as acquiring an antibiotic-resistant organism.[5] A point-prevalence study showed that up to 43% of long-term care residents had positive culture results for at least one antimicrobial-resistant pathogen.[6]

Guidelines for infection prevention and control in LTCFs encourage the program to include an antimicrobial stewardship component.[7] In addition, the US Centers for Medicare and Medicaid Services has mandated the implementation of antimicrobial stewardship programs (ASPs) in LTCFs since 2017.[8] Until recently, ASPs have existed mostly in the hospital setting, but they remain less well studied in LTCFs. Although the two different settings share the same antimicrobial stewardship goals, the structure and process differ considerably. LTCFs pose a unique challenge, with multiple factors that affect the quality of antibiotic prescribing decisions. For example, clinicians often have competing priorities and multiple roles, with many decisions being made off site.[9] Hospitals have invested considerably in developing ASPs, whereas most LTCFs lack the resources to emulate the ASP frameworks that have succeeded in acute-care hospitals.

There has not been consensus on specific strategies or resources required to support ASP in LTC settings.[10] Implementation requires flexibility to target local needs and can be hindered by the limited resources and evidence available reflecting the effectiveness of ASP overall or the effectiveness of specific ASP strategies.[10] This systematic review aimed to provide a comprehensive summary of the characteristics of antimicrobial stewardship interventions in LTC and to use meta-analysis to evaluate the impact of ASPs on overall antimicrobial use in LTCFs.