Antimicrobial Stewardship Programs Can Reduce Consumption

Antimicrobial stewardship programs can reduce the consumption of antimicrobials, including those on the WHO Watch List, in both hospital and non-hospital settings, according to a systematic review and meta-analysis published in JAMA Network Open.

Authors from around the Switzerland analyzed 52 studies that included more than 1.7 million patients in order to determine the association between antimicrobial stewardship programs and antibiotic use. The studies included in the meta-analysis included different health care and income settings, and were conducted between 2010 and 2020.

Overall, the study authors identified 19 prospective intervention studies, 12 randomized clinical trials, 10 quasi-experimental studies, 7 non-randomized controlled trials, and 4 retrospective cohorts. A majority of the studies were conducted in high-income countries, but 12 were conducted in low- or middle-income countries. The authors also noted that most of the studies were conducted in primary care sites (11) or tertiary care hospitals (32), though the remaining were conducted in general practitioner medical practices (3), ICUs (3), and nursing homes (3).

The common implementation methods for antimicrobial stewardship programs from the studies included:

• Implementation of training guidelines (such as training health workers on treatment practices, AMR, and updating guidelines)
• Decision support tools, which included electronic or paper algorithms that assisted with making treatment decisions
• Antibiotic restrictions (preauthorization)
• Prospective audit and feedback
• Tracking, such as monitoring, documenting, and reporting prescription practices and infection resistance patterns
• Pharmacy-based interventions
• Microbiology-based interventions, such as antibiotic susceptibility tests to guide decisions

The study authors wrote that the latest published literature suggests that antimicrobial stewardship programs can reduce antibiotic consumption by 19% and the use of restricted antimicrobial drugs by 27% in hospital settings. But, they noted, little data exists around the effectiveness of antimicrobial stewardship programs in low- or middle-income countries (where antimicrobial use is exceptionally high, they said) compared to high-income countries.

In their own meta-analysis, the study authors suggested that antimicrobial stewardship programs were associated with a 10% reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption rates. They wrote that they observed reductions in consumption across all antibiotic classes, including: penicillin and β-lactamase inhibitor combinations, macrolides, fluoroquinolones, cephalosporins, and carbapenems.

The investigators also said that there was “good news” for antibiotics included on the WHO Watch list (drugs that have a particularly high risk of selection of bacterial resistance). With appropriate antimicrobial stewardship programs, the study authors said, these drugs can be protected.

Antimicrobial stewardship programs were responsible for reducing antibiotic prescriptions by 6% in high-income countries, the study authors said, which is also aligned with previous studies. They also observed significant reductions in prescriptions in low- and middle-income countries after antimicrobial stewardship program implementation, but the study authors cautioned that there were only a small number of studies that took place in these settings.

“Given the challenges involved with the implementation of antimicrobial stewardship programs in low- and middle-income countries, including often limited availability and access to antibiotics, unavailable diagnostics, and weak adherence to treatment, further research on how to best implement antimicrobial stewardship programs without compromising the quality of care provided to patients in low- and middle-income countries is urgently needed,” the study authors wrote.