Clinical and Ecological Impact of an Educational Program to Optimize Antibiotic Treatments in Nursing Homes (PROA-SENIOR): A Cluster, Randomized, Controlled Trial and Interrupted Time-Series Analysis

Abstract

Background Antimicrobial stewardship programs (ASPs) are recommended in nursing homes (NHs), although data are limited. This study aimed to determine the clinical and ecological impact of an ASP for NHs. Methods We performed a cluster randomized controlled trial and a before-after study with interrupted time-series analyses in 14 NHs, for 30 consecutive months from July 2018 to December 2020, in Andalusia, Spain. Seven facilities implemented an ASP with a bundle of five educational measures (general-ASP) and 7 added one-to-one educational interviews (experimental-ASP). The primary outcome was the overall use of antimicrobials, calculated monthly, as defined daily doses (DDD) per 1000 residents-day (DRD). Results During the ASP implementation, the total mean antimicrobial consumption decreased by 31.2% (-16.72 DRD; p = 0.045) with respect to the pre-intervention period; the overall use of quinolones and amoxicillin-clavulanic acid dropped by 52.2% (p = 0.001) and 42.5% (p = 0.006) respectively; and the overall prevalence of MDRO decreased from 24.7% to 17.4% (p = 0.012). During the intervention period, 12.5 educational interviews per doctor were done in the experimental ASP-group; no differences were found in the total mean antimicrobial use between groups (-14.62 DRD; p = 0.25) and two unexpected SARS-CoV-2 waves affected the participating centers with significant increases in the overall mean use of total antimicrobials of 40% (51.56 DRD; p < 0.0001). Conclusion This study suggests that an ASP for NHs appears to be associated with a decrease in total consumption of antimicrobials and prevalence of MDRO. This trial did not find benefits associated with educational interviews probably due to the COVID-19 pandemic.

Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study

“…Different intervention strategies were used: audit and feedback [ 22 ], guidelines and implementation of interdisciplinary quality circles [ 23 ], educational sessions [ 24 ] and implementation of local ASB teams [ 26 ]. The primary outcomes were mainly number of antimicrobial prescriptions for UTI/ time period [ 24 , 25 ] or overall use of antimicrobials [ 23 , 26 ]. Our study focused a qualitative improvement of antimicrobial prescriptions for UTIs rather than an overall reduction of actual prescriptions.…”

“…Several studies describe successful antibiotic stewardship interventions for the prescription of antimicrobial substances for UTIs in long-term care facilities in different settings and countries [22][23][24][25][26][27]. Different intervention strategies were used: audit and feedback [22], guidelines and implementation of interdisciplinary quality circles [23], educational sessions [24] and implementation of local ASB teams [26]. The primary outcomes were mainly number of antimicrobial prescriptions for UTI/ time period [24,25] or overall use of antimicrobials [23,26].…”

Recommendations for the prevention of healthcare-associated infections in nursing homes

“…At this point it is particularly important to take into account antimicrobial stewardship (AMS) programmes for the appropriate management of antibiotics in this population [ 13 ] of which the incidence of C. difficile infection (CDI) would be an indirect marker of antibiotic use or abuse.…”

Development of Antimicrobial Defined Daily Dose (DDD) for the Pediatric Population

“…ASP monitor compliance with interventions that aim to optimize therapy and identify utilization patterns that warrant further investigation [4,5]. Their clinical and ecological benefits have been demonstrated in hospitals as well as in the community [6,7].…”