Table 1.

Summary of studies reviewed

Author	Year	Study design	Primary outcome	Secondary outcomes	Population	Intervention	Statistical significance (primary)	Statistical significance (secondary)	N	Quality	Acceptance rate
dos Santos[11]	2019	Quasi-experimental	Antimicrobial consumption	“Appropriateness,” antimicrobial resistance hand rub use, cost	55-bed community hospital in Brazil	PAF1	Significant reductions in the consumption of fluoroquinolones, first-generation cephalosporins, and ceftriaxone	“Appropriateness” and cost. Decrease in the rate of carbapenem-resistant Acinetobacter spp. isolation	11,088 prescriptions for 6163 patients	***	Not reported
Stevenson[12]	2018	Prospective quasi-experimental pilot study	Provider perceptions	Recommendation acceptance rate	Two rural VAMCs2 342 total acute-care and long-term care beds	Weekly meetings to discuss cases	N/A	N/A	259 cases over 78 sessions between both sites	*	73%
Shively[13]	2020	Prospective observational, semi-structured interviews	Antimicrobial consumption	ID consultation, cost	Two community hospitals with 461 total beds	PAF, Restriction, guideline development, provider education	Broad spectrum antimicrobial utilization decreased by 24.2% (341.1 vs. 258.7 DOT/1000 PDs – p < 0.001	ID consultation increased from 15.4 consults per 1000 PDs compared to 21.5 consults per 1000 PDs (p = 0.001). Estimated annualized savings $142,629.83	78,339 PDs3 prior to intervention; 37,639 PDs after intervention	***	88.9%
Beaulac[14]	2016	Uninterrupted time series analysis	Antimicrobial consumption	HA-CDI4, antimicrobial consumption by group	212 bed LTACH5	Daily audits of EMR6 with PAF via e-mail	Non-significant decrease in absolute consumption 32.8 DDD7/1000 PD (95% CI, − 77.0 to 11.4) (p = 0.14); significant change in slope from before to after the program (− 6.58 DDD/1000 PD per month [95% CI, − 11.48 to − 1.67]; p = 0.01)	Decrease HA-CDI (incidence rate ratio, 0.57 [95% CI, 0.35–0.92]; p = 0.02). Decrease anti-MRSA antibiotic use, decrease CDI therapy, increased antipseudomonal agents	885 recommendations about 734 patients	**	48%
dos Santos[15]	2013	Prospective observational	Appropriateness of empiric therapy	Appropriateness of empiric pneumonia therapy	50-bed community hospital in Brazil	Web-based consultation portal for providers	Significant increase in local guideline appropriate empiric therapy. 60% of prescriptions after interventions compared to 40% before. (p < 0.01)	Guideline appropriate empiric pneumonia therapy increased from 41 to 63% after intervention (p = 0.01)	81 consult requests	**	100%
Wilson[16]	2019	Prospective observational	Antimicrobial consumption	Duration of therapy, Mean ASI8, DOT9 per antibiotic class, ratio of DOT to antibiotic exposure, mean LOS, mortality	Two rural VAMCs 342 total acute care and long-term care beds	Weekly meetings to discuss cases	Significant decrease, in overall antibiotic DOT in acute and long-term care at both sites ranging from 8 to 22% all p < 0.001	ASI decreased in acute/long-term care at site A (p < 0.001), but unchanged to increase at site B. Only site A acute care had decreased length of therapy (p < 0.001). At site A fluoroquinolone and broad-spectrum beta-lactams usage decreased in acute + LTC. No change in LOS10 or mortality	259 cases over 78 sites between both sites	**	not reported
Yam[17]	2012	Observational	Number of ASP interventions	Rate of narrowing therapy to culture results, agreement between local ASP and remote ID physician, cost, CDI	141-bed rural community hospital	Develop local ASP with remote ID physician support. PAF, Cascade reporting	N/A	N/A	311 cases	*	86–100%
Ceradini[18]	2017	Observational “before and after”	Incidence of multidrug-resistant Enterobacteriaceae	HAI infections, LOS, cost, satisfaction, consumption	220-bed pediatric hospital “suburban”	Case discussion	Rate of multidrug-resistant organism isolation decreased from 104/1000 PDs to 79/1000 PDs. (p < 0.01)	No for LOS, HAI. N/A for others	683 patients to establish baseline: 531 patients post-intervention	**	not reported
Yan[19]	2020	Randomized control trial	Antimicrobial prescribing rate	Diagnostic shifting to mask inappropriate prescribing	Physicians practicing primary care via telemedicine. (outpatient)	Education compared to individualized feedback on prescribing patterns	For URI11 and bronchitis, there was a greater decrease in antibiotic prescription in the intervention group compared with the control group (decrease from 15 to 7.8% of prescriptions for URI diagnosis and 64 to 32.1% for bronchitis compared to control groups p < 0.001)	OR of visits with sinusitis or pharyngitis increased in the post-period compared with that in the pre-intervention period (aOR 1.36, 95% CI [1.29, 1.44], p < 0.001). However, a larger diagnostic shift was seen in the control group	31,473 visits in education arm and 25,519 visits in intervention arm met enrollment criteria	****	N/A
Wood[20]	2015	Observational	Antimicrobial consumption	Cost, consumption by class, antimicrobial resistance	6 community hospitals within one health system -413 total beds	PAF	No significant decrease in total antimicrobial consumption	Quinolone use decreased 57.4% in hospital B (p = 0.001), 65.9% in hospital D (p < 0.001), and 67.3% in hospital E (p < 0.001). Hospitals B, D, and E also had statistically significant decreases in antipseudomonal prescribing Average cost savings of $20,860.25 over 18 months	12,904 charts reviewed between the 6 sites	**	81–95%
Morquin[21]	2018	Prospective observational	Adherence to recommendations	Provider perceptions of program	2000-bed academic hospital system	PAF	N/A; 79% of diagnostic and 87% of therapeutic recommendations were accepted	N/A; most approved of the program	6994 chart reviews for 4173 inpatients	*	79–87%
Howell[22]	2019	Prospective observational	Time commitment	Barriers, cost	110-bed small community hospital	PAF	N/A, 3039 min over 3.5 months. 218 min per week or 3.6 h/week. 41.1% time spent on data analysis, 20.5% reporting, 18.4% preparing for meetings, 14.6% on education, and 5.4% spent on regulatory protocols and policies	N/A, barriers—workflow, communication, consistency. Average cost savings of $17,411.02 for patients with accepted ASP interventions compared to those rejected	724 alerts on 553 patients	*	11%

¹PAF, prospective audit and feedback

²VAMC, Veterans Affairs Medical Center

³PD, patient days

⁴HA-CDI, hospital-acquired Clostridioides difficile infection

⁵LTACH, long-term acute care hospital

⁶EMR, electronic medical record

⁷DDD, defined daily doses

⁸ASI, antibiotic spectrum index

⁹DOT, days of therapy

¹⁰LOS, length of stay

¹¹URI, upper respiratory tract infection