A systematic review and meta-analysis has found that antibiotic stewardship programs (ASPs) across the globe are associated with significant reductions in antibiotic prescriptions and consumption rates, researchers reported today in JAMA Network Open.
The paper, which analyzed 52 studies that included more than 1.7 million patients, found that ASPs in hospital and non-hospital settings were associated with a 10% reduction in antibiotic prescriptions and 28% reduction in the antibiotic consumption rate, with reductions observed across all antibiotic classes. ASPs were also linked to reduced antibiotic prescribing in pediatric hospitals and less use of antibiotics with high resistance potential.
Review included 12 studies in LMICs
With the emergence of antibiotic resistance as a major public health concern, ASPs have become an increasingly essential element of healthcare delivery over the last two decades, particularly hospitals in high-income countries (HICs). Using a variety of strategies, these programs aim to optimize the use of antibiotics, delay the emergence of antibiotic resistance, and ensure patient safety.
While many studies have evaluated the impact of ASP interventions on antibiotic use and patient outcomes, much of the research has been confined to specific hospitals or healthcare systems in high-income settings, with researchers comparing antibiotic use before and after ASP implementation. Such studies largely indicate that ASPs are associated with reduced antibiotic prescribing and consumption.
To get a more comprehensive sense of how ASPs affect antibiotic consumption in different healthcare settings around the world, and how they affect the use of different antibiotic classes, a team lead by researchers with the Swiss Tropical and Public Health Institute reviewed 109 studies that measured the association between ASPs and antibiotic consumption published from 2010 to 2020. Fifty-two studies with 1,794,889 participants were included in the meta-analysis.
The ASPs covered in the studies contained a variety of components, most commonly training and guidelines for healthcare workers, decision support tools (ie, electronic or paper-based treatment algorithms), active restrictions on antibiotic use, prospective audit and feedback of clinician prescribing, and pharmacy-based interventions. The main outcomes of the meta-analysis were the change in antibiotic prescriptions and the rate of antibiotic consumption (measured in defined daily doses per 1,000 patient-days) after the ASPs were implemented.
Of the 52 studies, 40 were conducted in healthcare settings in HICs and 12 in low- and middle-income countries (LMICs). Most studies were conducted in tertiary hospitals (32), followed by primary care sites (11), general practitioner medical practices (3), intensive care units (3), and nursing homes (3).
Prescriptions down 10%, consumption 28%
Based on 17 estimates, implementing ASPs was associated with a 10% (95% confidence interval [CI], 4% to 15%) decrease in antibiotic prescriptions. Pooled analysis of 34 studies suggested that ASPs were associated, on average, with a 28% reduction in antibiotic consumption (rate ratio [RR], 0.72; 95% CI, 0.56 to 0.94). Among healthcare settings, the largest reductions in antibiotic prescriptions were observed in pediatric settings (21%; 95% CI, 5% to 36%).
Stratifying the results by antibiotic class suggested large reductions in consumption of fluoroquinolones (42%), penicillin and beta-lactam inhibitor combinations (39%), carbapenems (31%), macrolides (26%), and cephalosporins (15%). The authors note, however, that these reductions are considered statistically nonsignificant because of the small number of studies.
When the researchers stratified the results using the World Health Organization's AWaRE (Access, Watch, and Reserve) classification system, they found a 28% reduction (RR, 0.72; 95% CI, 0.56 to 0.92) in the consumption of Watch antibiotics, which are broader-spectrum antibiotics not recommended for routine use because of their potential to select for resistance.
"In light of concerning increased use of Watch antibiotics globally, this is good news, as it suggests that protecting these drugs through appropriate ASPs is possible," the authors wrote.
The only individual ASP component associated with reduced antibiotic prescriptions was decision support systems (16%; 95% CI, 2% to 30%).
Stewardship in low-income settings
Another notable finding in the study came when the researchers stratified the results by income setting. In high-income settings, ASPs were associated with a 6% (95% CI, 2% to 9%) reduction in antibiotic prescriptions, compared with a 30% (95% CI, 10% to 50%) reduction in LMICs.
But the authors caution that only four of the studies that measured prescribing before and after ASP implementation were conducted in LMICs (three in China and one in Iran).
"While ASPs were associated with relatively large reductions in prescriptions in LMICs, this must be interpreted with caution due to the small number of studies currently available from LMICs," they wrote. "Uncertainty still remains about the outcomes of ASP in resource-limited settings."
They add that, because of all the challenges of implementing stewardship programs in low-resource settings, including limited availability and access to antibiotics and diagnostics and weak adherence to treatment, further research is needed on how best implement ASPs in LMICs without sacrificing patient care.