Nurse-led Antimicrobial Stewardship Intervention to Increase Antibiotic Appropriateness in Residential Aged Care Facilities

Nurse-led Antimicrobial Stewardship Intervention to Increase Antibiotic Appropriateness in Residential Aged Care Facilities

Stepped-wedge Cluster Randomised Controlled Trial to Increase Antibiotic Appropriateness in Residential Aged Care Facilities: a Nurse-led Bundled Antimicrobial Stewardship Intervention.

The study will explore the impact of a nurse-led bundled antimicrobial stewardship intervention on the appropriateness of antimicrobial use in residential aged care facilities. The intervention will be assessed in a stepped-wedge cluster randomised controlled trial across 14 residential aged care facilities over an 18-month period.

The study will explore the impact of a nurse-led bundled antimicrobial stewardship intervention on the appropriateness of antimicrobial use in residential aged care facilities (RACFs). The antimicrobial stewardship intervention will include the following components: Education Focused on antimicrobial stewardship and appropriate antimicrobial use Delivered face-to-face, via workbooks and fact sheets to aged care staff, general practitioners (GPs), pharmacists, and residents and families. Education will be delivered by the research coordinator. Guidelines Aged care-specific guidelines for the assessment and antimicrobial management of urinary tract infections, respiratory tract infections and skin and soft tissue infections. Antimicrobial management recommendations including empirical oral therapy, doses and duration of therapy. Communication Documentation for the assessment and antimicrobial management of infections. Nurse-led engagement with residents and families. Newsletters and online updates to highlight evidence-based prescribing practice Audit and feedback - Surveillance and feedback to prescribers on antimicrobial use and facility-level antimicrobial susceptibility data. The intervention bundle will first be implemented and tested for feasibility and acceptability over a 3-month period in two RACFs in Victoria, Australia. This tailored intervention will then be assessed in a stepped-wedge cluster randomised controlled trial across 12 RACFs over an 16-month period. A cluster of two facilities will each transition through three phases over the 16 month trial: Control phase: baseline data collection. Usual care at each facility. Transition phase: Delivery of education and integration of the intervention. No data collection. Intervention phase: implementation of the intervention and outcome data collection. Ongoing education to new and existing staff will be provided as required. Following the 16-month trial, the refined intervention bundle will be implemented nationally across a network of RACFs.

Antimicrobial Stewardship, Urinary Tract Infections, Respiratory Tract Infections, Skin and Soft Tissue Infections

Stepped-wedge design will see a staggered roll out of the intervention over 16 months. Each cluster of two facilities will commence in the control phase (2 months) and transition to the intervention phase until all facilities receive the intervention. A transition phase of 2 months between the control and intervention phase will occur to allow for education and integration of the intervention.

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Antimicrobials will be considered to be appropriate if minimum criteria for their initiation are met according to guidelines by the Society of Healthcare Epidemiology of America.

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Monthly biospecimen sampling will be collected from residents including nasal, faecal/rectal and wound specimens.

Assessed over a 12-month period during the trial (at least 2 months pre-intervention and 2 months post-intervention).

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Monthly biospecimen sampling will be collected from residents including nasal, faecal/rectal and wound specimens.

Assessed over a 12-month period during the trial (at least 2 months pre-intervention and 2 months post-intervention).

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Assessed from commencement of the intervention at each facility until the conclusion of the trial at 16 months

Semi-structured interviews conducted one-on-one or in moderated focus groups with stakeholders including aged care staff, GPs, residents and families.

Inclusion Criteria: Residents: All residents from 12 RACFs will have de-identified data collected including antimicrobial use, infection, hospitalisation and mortality. Residents or their guardians who provide informed consent to monthly biospecimen sampling and participation in one-on-one interviews or focus groups. Health professionals: - Health professionals (including aged care staff and GPs) who provide informed consent to participate in one-on-one interviews or focus groups. Exclusion Criteria: Residents or their guardians who do not consent to biospecimen sampling and/or participation in interviews/focus groups. Health professionals who do not consent to participate in interviews/focus groups.

Jokanovic N, Haines T, Cheng AC, Holt KE, Hilmer SN, Jeon YH, Stewardson AJ, Stuart RL, Spelman T, Peel TN, Peleg AY; START Trial Group. Multicentre stepped-wedge cluster randomised controlled trial of an antimicrobial stewardship programme in residential aged care: protocol for the START trial. BMJ Open. 2021 Mar 2;11(3):e046142. doi: 10.1136/bmjopen-2020-046142.