SYSTEMATIC REVIEW
Antibiotic Prescribing in Long-Term Care Facilities: A Meta-synthesis of Qualitative Research
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 Springerlink.com
Abstract
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 a.fleming@ucc.ie
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
