Research in context
Evidence before this study
We searched for all relevant studies published up to April 11, 2014, in Embase, Ovid MEDLINE, and PubMed. Each search addressed one of 14 antimicrobial stewardship objectives, and every search included terms for four predefined outcomes (clinical outcome, adverse events, costs, and resistance). An initial broad search strategy was used as the basis for all searches, to which specified strings were added that defined the 14 objectives being reviewed. Eligible study types were randomised controlled trials, non-randomised controlled trials, interrupted time series, and observational studies published in English, German, Spanish, French, or Dutch. We have found no systematic reviews published on this topic since our search.
Added value of this study
This systematic review revealed that the use of empirical therapy according to guidelines, de-escalation of therapy, switching from intravenous to oral treatment, therapeutic drug monitoring, use of a list of restricted antibiotics, and bedside consultation (especially in case of Staphylococcus aureus bacteraemia) are the most important objectives of the antimicrobial stewardship programme. The overall evidence for these objectives shows significant benefits for clinical outcomes, adverse events, costs, resistance rates, or combinations of these. However, the included studies were generally of low quality.
Implications of all the available evidence
For several antimicrobial stewardship objectives there is abundant, although low-quality, evidence on clinical outcomes, adverse events, costs, and resistance rates in hospitals. High-quality studies are now needed to provide better information on the effects of these objectives. We found no studies done in long-term care facilities, and research is needed in this setting. Our results combined with the previous critical appraisal of restrictive and persuasive strategies to improve appropriate antimicrobial use in patient care could guide hospital stewardship teams in improving the quality of antibiotic use.