title: Antibiotic prescribing in long-term care facilities: a meta-synthesis of qualitative research.
abstract: OBJECTIVE
  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 future antimicrobial stewardship strategies (AMS) in this setting.
  
  
  METHODS
  We searched Embase, PubMed, PsycInfo, Social 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 research. Thematic synthesis was used to integrate the emergent themes into an overall analytical theme.
  
  
  RESULTS
  The synthesis of eight qualitative studies indicated 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 between nurses, residents' families and doctors also influence decision making around antibiotic prescribing. The study also found that there is an acknowledged need for collaborative, evidence-based AMS specific to LTCFs, as antibiotic prescribing is heavily influenced by factors unique to this setting.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland, a.fleming@ucc.ie.
authors.forename: Aoife
authors.initials: A
authors.lastname: Fleming
authors.forename: Colin
authors.initials: C
authors.lastname: Bradley
authors.forename: Shane
authors.initials: S
authors.lastname: Cullinan
authors.forename: Stephen
authors.initials: S
authors.lastname: Byrne
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D006282:Health Personnel / Q000706:statistics & numerical data; D006801:Humans; D008134:Long-Term Care
chemical_list: D000900:Anti-Bacterial Agents
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