Antimicrobial stewardship in long-term care facilities: A scoping review of prevalence, key concepts, and gaps in the management of suspected urinary tract infections

• Persistent gaps in antimicrobial stewardship for UTIs in LTCFs • Overdiagnosis of asymptomatic bacteriuria drives unnecessary antibiotics • Diagnostic uncertainty and poor guideline adherence shape prescribing • Behavioural and system factors influence AMS practices in LTCFs • Multilevel framework proposed to guide future AMS interventions To systematically map existing literature on antimicrobial stewardship (AMS) practices and identify critical gaps in the management of suspected urinary tract infections (UTIs) in long-term care facilities (LTCFs) worldwide. A scoping review of studies published between 2014 and 2024 was conducted using EBSCOhost Advance (Ageline, MEDLINE Ultimate, and CINAHL Ultimate), PubMed, Scopus, Google Scholar, and TRIP databases. The review followed the Joanna Briggs Institute (JBI) methodology and was reported in accordance with the PRISMA-ScR checklist. Of 4,327 records screened, 74 studies (including 2 identified through hand searching) met inclusion criteria. Data were synthesised deductively into four overarching themes: (1) prevalence of UTIs in LTCFs over the past decade; (2) AMS practices and existing gaps; (3) underlying concepts and contextual factors shaping AMS implementation; and (4) risks associated with deviations from evidence-based practice. Theme 2 was further inductively analysed, revealing five subthemes: (i) suboptimal prescribing practices; (ii) diagnostic inaccuracies and misdiagnoses; (iii) limitations in documentation and review processes; (iv) deficits in knowledge, training, and guideline adherence; and (v) contextual and system-level influences. This review presents a global synthesis of evidence on the high prevalence of UTIs and persistent critical gaps in antimicrobial stewardship practices in LTCFs. We found there is widespread overdiagnosis of asymptomatic bacteriuria, driven by unreliable diagnostic practices, resulting in excessive exposure to antimicrobials and increased risk of antibiotic resistance and other adverse outcomes. The review also highlights the central role of frontline workers in UTI diagnosis and antimicrobial decisions. Further, it advocates for a targeted, behaviourally informed AMS initiative that emphasises diagnostic clarity and implementation of evidence-based practices in LTCFs.