Assignment: Antibiotic Prescribing

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Antibiotic Prescribing in Long-Term Care Facilities: A Meta-synthesis of Qualitative Research

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Aoife Fleming1 • Colin Bradley2 • Shane Cullinan1 • Stephen Byrne1

Published online: 2 April 2015

� The Author(s) 2015. This article is published with open access at


Objectives The objective of this review was to synthesize

the findings of qualitative studies investigating the factors

influencing antibiotic prescribing in long-term care facilities

(LTCFs). These findings will inform the development of fu-

ture antimicrobial stewardship strategies (AMS) in this setting.

Methods We searched Embase, PubMed, PsycInfo, So-

cial Science Citations Index and Google Scholar for all

qualitative studies investigating health care professionals’

views on antibiotic prescribing in LTCFs. The quality of

the papers was assessed using the Critical Appraisal Skills

Programme (CASP) assessment tool for qualitative re-

search. Thematic synthesis was used to integrate the

emergent themes into an overall analytical theme.

Results The synthesis of eight qualitative studies indi-

cated that health care professionals and administrators have

identified factors that influence antibiotic prescribing in

LTCFs. These factors include variations in knowledge and

practice among health care professionals, and the LTCF

context, which is unique given the complex patient

population and restricted access to doctors and diagnostic

tests. The social factors underpinning the interaction be-

tween nurses, residents’ families and doctors also influence

decision making around antibiotic prescribing. The study

also found that there is an acknowledged need for col-

laborative, evidence-based AMS specific to LTCFs, as

antibiotic prescribing is heavily influenced by factors

unique to this setting.

Conclusion This review highlighted the key contextual

challenges for AMS in LTCFs. The findings provide an in-

depth insight into the factors—such as the LTCF context,

social factors, variability in knowledge and prescribing

practices, and antimicrobial resistance—that impact on

antibiotic prescribing and AMS strategies. These factors

must be considered in order to ensure the feasibility and

applicability of future AMS interventions.

Key Points

The influences of the long-term care facility (LTCF)

context and social factors have an important impact

on antibiotic prescribing in this setting.

According to the findings of this review, future

antimicrobial stewardship strategies must emphasize

the importance of knowledge of guidelines and

antimicrobial resistance, and the strategies must be

specifically designed for implementation in the

LTCF setting.

1 Introduction

Recent studies evaluating the prescribing of antibiotics in

long-term care facilities (LTCFs) have found that antibiotic

prescribing is common, with reported annual prevalence

rates ranging from 47 to 79 % [1]. As many as 25–75 % of

Electronic supplementary material The online version of this article (doi:10.1007/s40266-015-0252-2) contains supplementary material, which is available to authorized users.

& Aoife Fleming [email protected]

1 Pharmaceutical Care Research Group, School of Pharmacy,

University College Cork, Cork, Ireland

2 Department of General Practice, University College Cork,

Cork, Ireland

Drugs Aging (2015) 32:295–303

DOI 10.1007/s40266-015-0252-2

antibiotic prescriptions in LTCFs are inappropriate in terms

of their indication, dose or duration of therapy [2]. Through

reductions in antibiotic prescribing and encouragement of

appropriate use of antibiotics, the rates of antimicrobial

resistance (AMR) and adverse drug events can be reduced

[3]. The few antimicrobial stewardship (AMS) intervention

studies that have been conducted in LTCFs have reported

modest effects, which were often not sustained [4, 5]. In

order to establish how best to address AMS strategies in

LTCFs, the factors that influence antibiotic prescribing

behaviours must be determined and understood. There is a

need for detailed awareness and understanding of the be-

haviour of all health care professionals involved in LTCF

antibiotic prescribing.

There have been several qualitative review papers

evaluating influences on antibiotic prescribing in primary

and secondary care settings [6–8]. Qualitative studies in-

vestigating antibiotic prescribing in LTCFs have been

conducted, but, to date, there has not been an overall

synthesis of these studies. Synthesis of knowledge is im-

portant to bring together the findings of individual studies

in order to further the understanding of a given issue [9]. A

qualitative meta-synthesis integrates and compares findings

across different studies, and the accumulated knowledge

may lead to development of a new theory, narrative or

interpretive translation [9, 10]. Synthesis of information

from existing qualitative studies may help to contribute to

AMS strategies in LTCFs.

The objective of this qualitative meta-synthesis was to

synthesize the qualitative research findings that have col-

lected health care professionals’ and administrators’ views

of the factors influencing antibiotic prescribing in LTCFs.

2 Methods

2.1 Search Strategy

The following databases were searched from their incep-

tion until July 2014: Embase, PubMed, PsycInfo, Social

Science Citations Index and Google Scholar. The search

strategy that was adopted included the following search

terms: (antibiotic* OR antibacterial* OR infection*) AND/

OR (attitude of health personnel) AND (nursing home* OR

long term care facilit*) AND (interview* OR ‘qualitative

research’). There were no date or language restrictions

imposed. We searched the reference lists of relevant arti-

cles to screen for any relevant studies.

2.2 Study Inclusion Criteria

The studies were included in the review if they met the

following criteria: (1) used qualitative data collection and

analysis methods; (2) were focussed on LTCF antibiotic

use; (3) included health care professionals (doctors, nurses

or pharmacists, or a combination of these groups) or LTCF

administrators in the sample; and (4) used qualitative

methods to evaluate an AMS intervention. In the case of

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