Pilot study of a multifaceted nurse-led antimicrobial stewardship intervention in residential aged care

Objective To evaluate the feasibility of a nurse-led antimicrobial stewardship (AMS) program in two Australian residential aged care homes (RACHs) to inform a stepped-wedged, cluster randomised controlled trial (SW-cRCT). Methods A mixed-methods pilot study of a nurse-led AMS program was performed in two RACHs in Victoria, Australia between July and December 2019. The AMS program comprised education, infection assessment and management guidelines, and documentation to support appropriate antimicrobial use in urinary, lower respiratory and skin/soft tissue infections. The program was implemented over three phases over five months: 1) pre-implementation education and integration (1-month); 2) implementation of the intervention (3-months); 3) post-intervention evaluation (1-month). Baseline RACH and resident data and weekly infection and antimicrobial usage was collected. Feedback on intervention resources and implementation barriers were identified from semi-structured interviews, online staff questionnaire and researcher field notes. Results Six key barriers to implementation of the intervention were identified and used to refine the intervention; aged care staffing and capacity, access to education, resistance to practice change, role of staff in AMS, leadership and ownership of the intervention at the RACH and organisation-level, and expectations from family. A total 61 antimicrobials were prescribed for 40 residents over the 3-month intervention period. Overall, 48% of antibiotics did not meet the minimum criteria for appropriate initiation (respiratory 73%; urinary: 54%; skin/soft tissue: 0%). Conclusions Several barriers and opportunities to improve the implementation of AMS in RACHs were identified. Findings were used to inform a revised intervention to be evaluated in a larger SW-cRCT. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the Australian Government Medical Research Future Fund (MRFF) Tackling Antimicrobial Resistance Program. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Alfred Hospital Human Research Ethics Committee gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors