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ObjectiveTo better understand barriers and facilitators that contribute to antibiotic overuse in long-term care and to use this information to inform an evidence and theory-informed program.MethodsInformation on barriers and facilitators associated with the assessment and management of urinary tract infections were identified from a mixed-methods survey and from focus groups with stakeholders working in long-term care. Each barrier or facilitator was mapped to corresponding determinants of behavior change, as described by the theoretical domains framework (TDF). The Rx for Change database was used to identify strategies to address the key determinants of behavior change.ResultsIn total, 19 distinct barriers and facilitators were mapped to 8 domains from the TDF: knowledge, skills, environmental context and resources, professional role or identity, beliefs about consequences, social influences, emotions, and reinforcements. The assessment of barriers and facilitators informed the need for a multifaceted approach with the inclusion of strategies (1) to establish buy-in for the changes; (2) to align organizational policies and procedures; (3) to provide education and ongoing coaching support to staff; (4) to provide information and education to residents and families; (5) to establish process surveillance with feedback to staff; and (6) to deliver reminders.ConclusionsThe use of a stepped approach was valuable to ensure that locally relevant barriers and facilitators to practice change were addressed in the development of a regional program to help long-term care facilities minimize antibiotic prescribing for asymptomatic bacteriuria. This stepped approach provides considerable opportunity to advance the design and impact of antimicrobial stewardship programs.

ates of antibiotic use in long-term care homes are highly variable and this variability is not associated with characteristics of long-term care residents. 1 However, high rates of antibiotic use are associated with antibiotic resistance and Clostridium difficile infection. 2-4 Antibioticassociated adverse events could be reduced if antibiotic overuse in long-term care was reduced. 5 Over 30% of antibiotics prescribed in long-term care are for urinary indications. 6 One practice that can contribute to overuse is the treatment of asymptomatic bacteriuria. 7,8 Asymptomatic bacteriuria is the presence of bacteria in the urine in the absence of clinical signs and symptoms of a urinary tract infection. 7 The prevalence of asymptomatic bacteriuria in long-term care residents is high: it is estimated that 15%-30% of men and 25%-50% of women have the condition. 9,10 Several randomized controlled trials have found that the systematic screening and treatment of asymptomatic bacteriuria in long-term care is not beneficial to residents. 11,12 The Infectious Diseases Society of America and the Association of Medical Microbiology and Infectious Disease Canada both discourage this practice. 8,13 In many long-term care homes, treatment of asymptomatic bacteriuria accounts for most urinary antibiotic use. 14 Public Health Ontario, an arm's length government agency that provides scientific expertise and technical support to front-line health care workers, developed a multistrategy Urinary Tract Infection Program to improve diagnosis and management of urinary tract infections in noncatheterized residents of long-term care homes. The program built on several studies showing that interventions designed to improve diagnosis and management of urinary tract infections are effective at reducing antimicrobial use in long-term care homes. 5,15,16 Rather than focusing on a single guideline, the program focused on 5 practice changes by incorporating 9 strategies to address specific barriers to practice change. 17 We aimed to address 2 questions before further rollout of the program in the province: first, whether the program decreased