TABLE 1.
Individual studiesa
| Study designation (reference) | Pub yr | Mid-yr | Origin | Study design | ASP type | Duration | Antimicrobial restriction/control | % change | Age | Setting |
|---|---|---|---|---|---|---|---|---|---|---|
| Amer MR (47) | 2013 | 2010 | Saudi Arabia | Comparative historically controlled without intervention vs prospective arm under active ASP | Formulary restriction; preapproval strategies (antimicrobial order forms); prospective audit and feedback; education; guidelines; pharmacodynamic dose optimization; antimicrobial cycling | Pre-ASP: 6 mo (7–12/2009); ASP: started on 3/2011 | Piperacillin-tazobactam, imipenem, meropenem, vancomycin, tigecycline | −0.84 | Adults | Medical 20-bed ICU (of 894-bed tertiary hospital) |
| Apasarthanarak A (48) | 2006 | 2004 | Thailand | Prospective cohort; pre-ASP vs prospective cohort; post-ASP | Education; feedback: bedside discussion; use of IV antibiotic prescription forms; use of antibiogram; computerized system recording | Pre-ASP: 1 yr (7/2003–6/2004); post-ASP: 1 yr 7/2004–6/2005 | No | −0.13 | 65 ± 18 vs 66 ± 19 | 350-bed tertiary care university hospital |
| Bantar C (35) | 2003 | 2000 | Argentina | Comparative historically controlled without intervention vs prospective arm under active ASP | Introduction of an optional, and later obligatory, antibiotic order form; feedback: bedside discussion toward modification of prescription | Pre-ASP: 6 mo (1– 6/1999); ASP: 2 yrs (6/1999–6/2001) | No | −0.36 | Adults | 250-bed public teaching hospital & 10-bed ICU |
| Borde JP 1 (39) | 2015 | 2012 | Gernamy | Prospective cohort (pre- and post-ASP) | Daily rounds; written pocket-sized; formats of guidelines | Pre-ASP: >2 yrs (1/2011–3/2013); ASP: 4/2013; post-ASP: 1 yr (4/2013–3/2014) | Third-generation cephalosporins, fluoroquinolones | 0.02 | NA | 200-bed community hospital and 10-bed ICU |
| Borde JP 2 (37) | 2014 | 2010 | Germany | Prospective cohort medical service (applied ASP) vs surgical service (control) | Guideline; revision: written pocket-sized; formats and hospital intranet; information and education; regular ward rounds and intensified ID consultations; feedback; prospective audit | Pre-ASP: 3 yrs (1/2008–11/2011); ASP: 12/2011; post-ASP: >1 yr (1/2012–3/2013) | Cephalosporins, fluoroquinolones | −0.14 | NA | 300-bed medical service (of a 1,600 bed-academic teaching hospital) |
| Borde JP 3 (38) | 2015 | 2010 | Germany | Prospective cohort | Guideline revisions: written, pocket-sized formats and hospital intranet; information; education; intensified infectious diseases consultation and standardized treatment protocol | Pre-ASP: 3 yrs (1/2008–10/2011); ASP: 10/2011; post-ASP: >2 yrs (11/2011–10/2013) | Cephalosporin (especially third generation) fluoroquinolones | −0.07 | NA | Emergency department −39-bed capacity (of a 1,600-bed academic teaching hospital) |
| Boyles TH (40) | 2013 | 2012 | Cape Town, South Africa | Retrospective cohort- control arm; prospective cohort-intervention arm | Antibiotic prescription chart; antibiotic stewardship ward rounds; audit of antibiotic prescription chart use | Pre-ASP: 1 yr (1–12/2011); ASP: 11/22/2011; post-ASP: 1 yr (1–12/2012) | NA | −0.2 | 48 ± 18 vs 50 ± 18 | Two 32-bed medical wards |
| Bozkurt F (49) | 2014 | 2013 | Turkey | Cross-sectional study (before and after the intervention | Guidelines; education (monthly seminars); feedback; audit of antimicrobial prescription in terms of duration and appropriateness of the treatment | ASP: 5/16/2011–5/23/2015 | −0.33 | NA | 672-bed tertiary teaching and research hospital center with 6 ICUs, 10 medical and surgical units | |
| Cisneros JM (29) | 2014 | 2011 | Spain | Prospective recorded intervention | Antibiotic prescribers based on counseling interviews; guidelines | ASP: 1–3/2011; post-ASP: 9–12/2011 | No | −0.26 | NA | 1,251-bed tertiary care teaching hospital with 90 ICU beds and a transplant/BMT unit |
| Cook PP (30) | 2004 | 2001 | Louisville, KY | Retrospective cohort- control arm; prospective cohort-intervention arm | Enhanced feedback after two preauthorization approvals for restricted antibiotics; treatment days for controlled antibiotics | Pre-ASP: 2 yrs (1999–2000); ASP: 1/2001 introduced; post-ASP: 2 yrs (2002–2003) | Restricted: amikacin, caspofungin, traconazole, linezolid, quinupristin-dalfopristin, valganciclovir, oral vancomycin, amphotericin lipid formulation; controlled: ampicillin-sulbactam, azithromycin, aztreonam, cefepime, cefotaxime, ceftriaxone, ciprofloxacin, clindamycin, ertapenem, fluconazole, ganciclovir, imipenem-cilastatin, meropenem, moxifloxacin, piperacillin-tazobactam, tobramycin, vancomycin (IV) | −0.26 | Adults | 731-bed tertiary-care teaching hospital |
| Gould IM (41) | 2000 | 1994 | Scotland, United Kingdom | Prospective cohort for both arms | Drug restriction | Pre-ASP: >1 yr (1992–1993); ASP: 3/1993 introduced; post-ASP: >1 yr (1996–1997) | Didanosine, clarithromycin, zalcitabine, lipid; amphotericin, stavudine, meropenem, saquinavir, ceftriaxone, ritonavir, cefixime, indinavir, fosfomycin, famciclovir, ceftibuten, itraconazole, ofloxacin, terbinafine, valciclovir, azithromycin | 0.17 | NA | Multicenter: acute tertiary referral/teaching hospital, small district general hospital, long-stay hospital for the elderly, several small community hospitals, and two psychiatric hospitals |
| Hou D (31) | 2014 | 2011 | Taishan, China | Retrospective cohort- control arm; prospective cohort-intervention arm | Formulary restriction; preauthorization; education | Pre-ASP: 6 mo (10/2010–3/2011); ASP: 4/2011–8/2011; post-ASP: 6 mo (10/2011–3/2012) | Quinolones (perioperative use) | −0.27 | 53.10 ± 19.43 vs 54.59 ± 18.07 | 12-bed ICU (700-bed tertiary hospital) |
| Kim YC (50) | 2013 | 2008 | South Korea | Retrospective cohort- control arm; prospective cohort-intervention arm | Computerized prescription restriction; formulary restriction; report outcomes of the ASP | Pre-ASP: 1 yr (2006); ASP: 8/2008 started; post-ASP: 1 yr (2011) | Third-generation cephalosporin: surgery prophylaxis; aminoglycosides: surgery prophylaxis; inappropriate antibiotic combinations | −0.13 | NA | 2,000-bed tertiary hospital |
| Lin YS (32) | 2013 | 2010 | Taipei, Taiwan | Retrospective cohort- control arm; prospective cohort-intervention arm | Formulary, restriction; education concept; antibiotic stewardship, ward rounds: bedside evaluation, prospective audit, report outcomes of the program regularly to all staff | Pre-ASP: 6 mo (1–7/2009); ASP: 7/2009 introduced; post-ASP: 1 yr (7/2009–6/2012) | Imipenem, meropenem, vancomycin, tigecycline, colistin, linezolid | −0.21 | NA | 415-bed community public teaching hospital. |
| Mach R (42) | 2007 | 2002 | Czech Republic | Prospective computerized survey | New guidelines for antibiotic prophylaxis based on local microbial resistance patterns; prior authorization for the restricted antibiotics | Pre-ASP: 1 yr (2000–2001); ASP: 2002 introduced; post-ASP: 1 yr (2003–2004) | Aminopenicillins and β-lactamase inhibitors, piperacillin with β-lactamase inhibitors; meropenem, cefalothin, cefapirin, cefazolin, etc.; fluoroquinolones, colistin, vancomycin (prior authorization for the restricted ones) | −0.58 | NA | 500-bed general hospital |
| Meyer E (33) | 2007 | 2003 | Germany | Segmented regression analysis | Revised guidelines for pneumonia management; education | Pre-ASP: 1 yr (2002–2003); ASP: January 2004 introduced; post-ASP: 1 yr (2005) | No (revised guidelines: carbapenem removal for pneumonia) | −0.34 | Adults | Neurosurgical 12-bed ICU |
| Ng CK (51) | 2008 | 2004 | Hong Kong | Pretest/posttest analysis | Policy and guideline formulation; education; feedback; monthly antibiotic consumption; cost monitoring; antimicrobial susceptibility pattern reporting | Pre-ASP: 1 yr (7/2003–6/2004); ASP: 7/2004 introduced; post-ASP: 1 yr (7/2004–6/2005) | Antipseudomonal cephalosporins, carbapenems, IV vancomycin, IV fluoroquinolones, IV macrolides, fluconazole. | −0.06 | 71.4 ± 16.6 vs 72.9 ± 15.9 | 1,800-bed regional hospital providing acute care service |
| Nitsch-Osuch A 1 (43) | 2015 | 2013 | Poland | Retrospective analysis before and after of ASP implementation | Written guidelines for antibiotic prescription; preauthorization approval for broad-spectrum antibiotics (e.g., glycopeptides and carbapenems) | Pre-ASP: 1 yr (2012); ASP: 2013 introduced; post-ASP: 1 yr (2013) | Broad-spectrum antibiotics (e.g., glycopeptides and carbapenems) | 0.05 | 0-18 | General pediatric 21-bed ward (of an academic hospital) |
| Nitsch-Osuch A 2 (44) | 2015 | 2012 | Poland | Retrospective analysis before and after of ASP implementation | Preauthorization approval of broad-spectrum antibiotics | Pre-ASP: 1 yr (2011); ASP: 2012 introduced; post-ASP: 1 yr (2012) | Broad-spectrum antibiotics (e.g., glycopeptides and carbapenems) | −0.31 | neonates | 10-bed special neonatal care units (of an academic hospital) |
| Niwa T (52) | 2012 | 2010 | Japan | Retrospective cohort- control arm; prospective cohort-intervention arm | Review of antimicrobial orders-phone contact; IV antimicrobial administration limited to 2 weeks duration, otherwise preauthorization approval strategy; appropriateness of duration; education; feedback over mobile phone; printed information | Pre-ASP: 1 yr (8/2008–7/2009); ASP: 2 yrs (8/2009–7/2011) | No | −0.08 | 54 ± 22.5 vs 56 ± 22.6 | National 606-bed university hospital |
| Pate PG (36) | 2012 | 2010 | Dallas, TX | Retrospective cohort- control arm; prospective cohort-intervention arm | Prospective audit; ID consultation | Pre-ASP: <1 yr (1–11/2009); ASP: >1 yr (12/2009–2/2011) | No | −0.21 | 67 (54–77) vs 68 (56–77) | 60-bed LTACH & 6-bed high-acuity patients |
| Peto Z (45) | 2008 | 2003 | Hungary | Segmented regression analysis | ICU/ID specialist consultant in rounds and over telephone; preauthorization approval on every antibiotic apart from antibiotics for surgical prophylaxis | Pre-ASP: (2 yrs) 2000–2002; ASP: 11/2002; post-ASP: (2 yrs) 2003–2005 | All apart from antibiotics for surgical prophylaxis | −0.38 | 56.3 ± 17.2 vs 56.8 ± 17.6 | 6-bed surgical ICU (of a university tertiary referral hospital) |
| Ruttimann S (46) | 2004 | 1998 | Switzerland | Quasiexperimental study | Preauthorization approval for restricted drugs; educational program; written guidelines | Pre-ASP: 1 yr (1996); ASP: 1997 introduced; post-ASP: 1 yr (2001) | Ceftriaxone, ceftazidime, piperacillin-tazobactam, imipenem-cilastatin, vancomycin | 0.5 | Adults | 80-bed tertiary care center with 80 beds (including ICU) |
| Storey DF (34) | 2012 | 2010 | Dallas, TX | Retrospective cohort- control arm; prospective cohort-intervention arm | ASP team audited antimicrobial prescriptions provided nonbinding feedback | Pre-ASP: 8 mo (1/2009–8/2009); ASP: 9–12/2009; post-ASP: >1 yr (9/2009–12/2010) | No | −0.16 | 57.4 ± 18.6 vs 57.4 ± 18.7 | 43-bed medical-surgical services (24-bed medical-surgical wards, 11-bed; step-down unit and 8-bed ICU) |
| Yeo CL 1 (28) | 2012 | 2009 | Singapore | Prospective interrupted time-series study | Non-binding prospective audit of antibiotic prescription with direct feedback via a written form for discontinuation, change or de-escalation; drug restriction | Pre-ASP: 1.5 yrs (1/8/2008–6/30/2009); ASP: 7/2009; post-ASP: 1.5 yrs (8/1/2009–6/30/2010) | Carbapenems; third-generation and fourth-generation cephalosporins, piperacillin-tazobactam, vancomycin | 0.21 | Adults | National university cancer institute (including BMT) |
| Yeo CL 2 (28) | 2012 | 2009 | Singapore | Prospective interrupted time-series study | Nonbinding prospective audit of antibiotic prescription with direct feedback via a written form for discontinuation, change, de-escalation, change route; drug restriction | Pre-ASP: 1/8/2008–6/30/2009; ASP: 7/2009; post-ASP: 8/1/2009–6/30/2010 | Carbapenems; third-generation and fourth-generation cephalosporins, piperacillin-tazobactam, vancomycin | 0.29 | Adults | 990-bed tertiary public teaching hospital |
a
Characteristics of 26 studies: publication year, mid-year, origin, study design, duration of study, antimicrobials in restriction if applicable, the percent change of total antibiotic consumption, the mean age of the participants, and the type of setting. Note that study designations as set in column 1 correspond to the study designations used in the figures. BMT, bone marrow transplant unit.