Background and objective:
The spread of antimicrobial resistance in long-term care facilities (LTCFs) represents an important challenge. The objectives were to identify barriers arisen with implementation of antimicrobial stewardship (AMS) programs in LTCFs and to describe novel strategies to overcome them, aiming to provide guidance for effective implementation of AMS programs in LTCFs.

Methods:
A scoping review was conducted through Ovid-MEDLINE, CINAHL, Embase, Cochrane Central on studies published up to 22 July 2021, considering eligible both quantitative and qualitative studies on adults residents of LTCFs experiencing an AMS program. Outcomes assessed were barriers and facilitators for implementation of interventions, then synthesized using a macro-meso-micro framework.

Results:
Of 2921 papers, 71 studies met inclusion criteria. The main identified macro-level themes were policy, research, and public engagement. The most frequently cited macro-level barrier was lack of policies, protocols, guidelines and recommendations concerning AMS in LTCFs. The main identified meso-level themes were resources, program characteristics, surveillance; lack of funding and resources for AMS programs was the most cited barrier. The main identified micro-level themes were resources, surveillance, organization of work, clinician factors, patient characteristics, and patient-clinician relationship. Again, the most common theme was lack of resources. The most frequently cited macro-level strategy was developing policies, protocols, guidelines, and recommendations for AMS in LTCFs. Meso-level strategies were including regular auditing and providing feedback to prescribers in AMS programs, tailoring strategies to the local context, addressing site-specific potential implementation barriers, and fostering interprofessional engagement with participatory strategies. Strategies at micro-level were cited by the greatest number of studies; the most commonly cited theme was the organization of work.

Conclusions:
By categorizing barriers and strategies according to the macro-meso-micro framework, this study could be useful to guide improvements in policy, programs and action, improving healthcare quality and patient safety in LTCFs.