ARCH was a multidisciplinary, four Work Package, project involving key stakeholders to improve understanding, and ultimately practice, around infection detection/management and antibiotic use in care homes for older people. WP1 used statistical analysis of anonymised quantitative data, finding wide variation in antibiotic prescribing rates, and informing selection of care homes for WP2/3. WP1 data are held by Health Informatics Centre (HIC), University of Dundee (https://www.dundee.ac.uk/hic/). WP2 and WP3 used anthropology, sociology and behavioural science to investigate individual, socio-cultural and contextual factors influencing antibiotic use, conducting ethnographic observations (61 periods, ~315hrs), interviews (n=101) and surveys (n=76) with care home managers, nurses, carers, senior carers, GPs, advanced nurse practitioners, pharmacists, residents and their relatives, across 7 care homes (survey broader). Observations and interviews highlighted variation in how suspected infections were identified and managed. Identified factors influencing antibiotic prescribing included: limited training around infections; lack of confidence in distinguishing infections from other conditions, and in ‘watchful waiting’; habitual/routine use of urine dip testing; the importance of communication internally and externally; limited handover documentation; duty of care linked to worry about ‘missing something’; antibiotic resistance a distant problem; pressure from family and residents, and; antibiotic stewardship not seen as care home staff’s role. WP4: Behavioural science intervention development frameworks were applied to integrated WP1-3 findings to identify candidate intervention strategies, prioritised by a co-design workshop (20 care home sector participants) into an intervention including: training (videos and online), appointment of Antibiotic Champions, an Assessment Flowchart, a Monitoring Tool, an SBAR (Situation-Background-Assessment-Recommendation) form for communication between care homes and GPs/ANPs, and reminder stickers. The feasibility trial was impacted by COVID-19 but some in-situ testing and online focus groups found that participants liked the intervention and were keen to engage. Implementation challenges included understaffing, protecting time for training, and balance between standardisation and individual contextual adaptation.Bacteria that cause common infections are becoming increasingly resistant to currently available antibiotics. Antibiotics are essential in modern healthcare but their use drives the development of resistance as bacteria develop ways of surviving their effects. Previous research has found that antibiotics are often used when they are not needed, which increases the development of resistance in bacteria. Older people living in care homes are prescribed many more antibiotics than average and as a result often get antibiotic resistant infections later, which are then harder to treat. The amount of antibiotics used in different care homes varies a lot but we don't really know why. Most research on finding ways to safely reduce antibiotic use has been carried out in hospitals or GP surgeries rather than care homes. There is general agreement that antibiotic use in care homes could and should be safely reduced. However, to design effective approaches to reducing antibiotic prescribing for care home residents we need to understand more about how, when and why they get prescribed, from the perspectives of nurses, carers, GPs, and residents and their relatives. Researchers with different areas of expertise will work together in a four-stage project: 1. Measuring patterns of antibiotic use (epidemiology): We will analyse information on antibiotic prescribing and antibiotic resistance for all care home residents in two Scottish health board regions. As well examining the link between antibiotic prescribing and later antibiotic resistance, this will help us better understand how common antibiotic use is, which residents are prescribed, and variation in prescribing between care homes. This information will also be used to invite care homes with different patterns of antibiotic use to participate in the next stages of the project. 2. Understanding how and why antibiotic prescribing happens in different care homes (sociology and social anthropology): We will work with staff, GPs, residents and relatives in eight care homes. We will observe how staff and GPs work together and react to residents being unwell, and how this leads to antibiotic prescribing. We will also interview staff, GPs, residents and relatives to understand how the way the care home and general practices are organised influences the care different residents receive.

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