Factors associated with antibiotic use in long-term care facilities: a systematic review of quantitative studies
Résumé
Background Effectiveness of antimicrobial stewardship programs in long-term care facilities (LCTFs), where antimicrobial resistance is frequent, remains unclear. We aimed to identify factors associated with antibiotic use in LTCFs. Materials We conducted a systematic review of studies retrieved from PubMed, Cochrane Library, Embase, APA PsycArticles, APA PsycINFO, APA PsycTherapy, ScienceDirect and Web of Science. Participants were LTCF residents, their family, and/or carers. We included quantitative studies investigating factors associated with antibiotic use and performed a qualitative narrative synthesis of the findings. For each factor, if >50% of the studies investigating it showed a statistically significant association in the same direction, we used the term “factor with a trend”. For each factor with a trend, we calculated a causation score (CS) based on the sum of Hill’s criteria (temporality, strength, dose-response relationship, internal consistency, reproducibility; each coded 0/1) and ranging from 0 to 5. Results Out of 7,333-screened records, we included 56 articles. Most studies investigated resident-level (n=29/56) and/or facility-level factors (n=31/56), and fewer prescriber-level ones (n=8/56). Resident-level factors with a positive trend (i.e., associated with a higher volume of antibiotic prescriptions, Figure) included comorbidities (CS=5), history of infection (CS=5), indwelling urinary catheter (CS=4), potential signs of infection (e.g., fever, CS=3), positive urine culture/dipstick results (CS=3). Conversely, dementia showed a negative trend (CS=5). Facility-level factors with a positive trend included infection rate (CS=5), prevalence of after-hours medical practitioner visits (CS=4), prevalence of residents with a recent history of urine culture testing (CS=3), staff turnover (CS=2), and number of prescribers (CS=2). The presence of an on-site coordinating physician showed a negative trend (CS=2). At the prescriber-level, higher antibiotic prescribing was associated with high prescription rate for antibiotics in the previous year (CS=4). Conclusions Considered as a whole, these factors might result in a complex interplay of diverse factors underpinning antibiotic use in LCTFs. This includes not only individual, but also organisational and other contextual factors associated with antibiotic use, that have been rarely addressed in antimicrobial stewardship programs so far.
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