Skip to main content Accessibility help

Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

  • Brittin Wagner (a1) (a2), Gregory A. Filice (a2) (a3), Dimitri Drekonja (a2) (a3), Nancy Greer (a1), Roderick MacDonald (a1), Indulis Rutks (a1), Mary Butler (a4) and Timothy J. Wilt (a1) (a2)...



Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.


Systematic review.


Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.


Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.


Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.


Corresponding author

MPH, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Mail Code 111-O, Minneapolis, MN 55417 (


Hide All
1. Spellberg, B, Bartlett, JG, Gilbert, DN. The future of antibiotics and resistance. N Engl J Med 2013;368:299302.
2. Jacob, JT, Gaynes, RP. Emerging trends in antibiotic use in US hospitals: quality, quantification and stewardship. Expert Rev Anti Infect Ther 2010;8:893902.
3. Kollef, MH, Sherman, G, Ward, S, Fraser, VJ. Inadequate antimicrobial treatment of infections. Chest 1999;115:462474.
4. Ibrahim, EH, Sherman, G, Ward, S, Fraser, VJ, Kollef, MH. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 2000;118:146155.
5. Micek, ST, Welch, EC, Khan, J, et al. Empiric combination antibiotic therapy is associated with improved outcomes against sepsis due to gram-negative bacteria: a retrospective analysis. Antimicrob Agents Chemother 2010;54:17421748.
6. Shehab, N, Patel, PR, Srinivasan, A, Budnitz, DS. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis 2008;47:735743.
7. Zahar, JR, Rioux, C, Girou, E, et al. Inappropriate prescribing of aminoglycosides: risk factors and impact of an antibiotic control team. J Antimicrob Chemother 2006;58;651656.
8. Ray, WA, Murray, KT, Meredith, S, Narasimhulu, SS, Hall, K, Stein, CM. Oral erythromycin and the risk of sudden death from cardiac arrest. N Engl J Med 2004: 351:10891096.
9. Ray, WA, Murray, KT, Hall, K, Arbogast, PG, Stein, CM. Azithromycin and the risk of cardiovascular death. N Engl J Med 2012;366:18811890.
10. MacDougall, C, Polk, RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005; 18:638656.
11. Dellit, TH, Owens, RC, McGowan, JE Jr, Gerding, DN, Weinstein, RA, Burke, JP. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159177.
12. Ohl, CA, Dodds Ashley, ES. Antimicrobial stewardship programs in community hospitals: the evidence base and case studies. Clin Infect Dis 2011;53(suppl 1):S23S28.
13. Pope, SD, Dellit, TH, Owens, RC, Hooton, TM. Results of the survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol 2009;30:9798.
14. Davey, P, Brown, E, Charani, E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4:CD003543. doi: 10.1002/14651858.
15. Cochrane Effective Practice and Organisation of Care Group. Accessed June 5, 2013.
16. Shea, BJ, Grimshaw, JM, Wells, GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10.
17. Owens, DK, Lohr, KN, Atkins, D, et al. AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions—Agency for Healthcare Research and Quality and the Effective Health Care Program. J Clin Epidemiol 2010;63:513523.
18. Lesprit, P, Landelle, C, Brun-Buisson, C. Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial. Clin Microbiol Infect 2013;19:E91E97.
19. Camins, BC, King, MD, Wells, JB, et al. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol 2009;30:931938.
20. Masia, M, Matoses, C, Padilla, S, et al. Limited efficacy of a nonrestricted intervention on antimicrobial prescription of commonly used antibiotics in the hospital setting: results of a randomized controlled trial. Eur J Clin Microbiol Infect Dis 2008;27:597605.
21. Weiss, CH, Moazed, F, McEvoy, CA, et al. Prompting physicians to address a daily checklist and process of care and clinical outcomes. Am J Respir Crit Care Med 2011;184:680686.
22. Manuel, O, Burnand, B, Bady, P, et al. Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards. J Hosp Infect 2010;74:326331.
23. Elligsen, M, Walker, SAN, Pinto, R, et al. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012;33:354361.
24. Standiford, HC, Chan, S, Tripoli, M, Weekes, E, Forrest, GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol 2012;33:338345.
25. Teo, J, Kwa, ALH, Loh, J, Chlebicki, MP, Lee, W. The effect of a whole-system approach in an antimicrobial stewardship programme at the Singapore General Hospital. Eur J Clin Microbiol Infect Dis 2012;31:947955.
26. Bornard, L, Dellamonica, J, Hyvernat, H, et al. Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit. Med Mal Infect 2011;41:480485.
27. Dunn, K, O’Reilly, A, Silke, B, Rogers, T, Bergin, C. Implementing a pharmacist-led sequential antimicrobial therapy strategy: a controlled before-and-after study. Int J Clin Pharm 2011;33:208214.
28. Cairns, KA, Jenney, AWJ, Abbott, IJ, et al. Prescribing trends before and after implementation of an antimicrobial stewardship program. Med J Aust 2013;198:262266.
29. Liebowitz, LD, Blunt, MC. Modification in prescribing practices for third-generation cephalosporins and ciprofloxacin is associated with a reduction in meticillin-resistant Staphylococcus aureus bacteraemia rate. J Hosp Infect 2008;69:328336.
30. Magedanz, L, Silliprandi, EM, dos Santos, RP. Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study. Int J Clin Pharm 2012;34:290294.
31. Yeo, CL, Chan, DSG, Earnest, A, et al. Prospective audit and feedback on antibiotic prescription in an adult hematology-oncology unit in Singapore. Eur J Clin Microbiol Infect Dis 2012;31:583590.
32. Rattanaumpawan, P, Sutha, P, Thamlikitkul, V. Effectiveness of drug use evaluation and antibiotic authorization on patients’ clinical outcomes, antibiotic consumption, and antibiotic expenditures. Am J Infect Control 2010;38:3843.
33. Peto, Z, Benko, R, Matuz, M, Csullog, E, Molnar, A, Hajdu, E. Results of a local antibiotic management program on antibiotic use in a tertiary intensive care unit in Hungary. Infection 2008;36:560564.
34. Mamdani, M, McNeely, D, Evans, G, et al. Impact of a fluoroquinolone restriction policy in an elderly population. Am J Med 2007;120:893900.
35. Aldeyab, MA, Kearney, MP, Scott, MG, et al. An evaluation of the impact of antibiotic stewardship on reducing the use of high-risk antibiotics and its effect on the incidence of Clostridium difficile infection in hospital settings. J Antimicrob Chemother 2012;67:29882996.
36. Lewis, GJ, Fang, X, Gooch, M, Cook, PP. Decreased resistance of Pseudomonas aeruginosa with restriction of ciprofloxacin in a large teaching hospital’s intensive care and intermediate care units. Infect Control Hosp Epidemiol 2012;33:368373.
37. Schnoor, M, Meyer, T, Suttorp, N, et al; the CAPNETZ Study Group. Development and evaluation of an implementation strategy for the German guideline on community-acquired pneumonia. Qual Saf Health Care 2010;19:498502.
38. Schouten, JA, Hulscher, MEJL, Trap-Liefers, J, et al. Tailored interventions to improve antibiotic use for lower respiratory tract infections in hospitals: a cluster-randomized, controlled trial. Clin Infect Dis 2007;44:931941.
39. Fowler, S, Webber, A, Cooper, BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007;59:990995.
40. Talpaert, MJ, Rao, GG, Cooper, BS, Wade, P. Impact of guidelines and enhanced antibiotic stewardship on reducing broad-spectrum antibiotic usage and its effect on incidence of Clostridium difficile infection. J Antimicrob Chemother 2011;66:21682174.
41. Goldwater, SH, Milkovich, G, Morrison, AJ, Lindgren, B. Comparison of therapeutic interchange with standard educational tools for influencing fluoroquinolone prescribing. Am J Health Syst Pharm 2001;58:17401745.
42. Meyer, E, Buttler, J, Schneider, C, et al. Modified guidelines impact on antibiotic use and costs: duration of treatment for pneumonia in a neurosurgical ICU is reduced. J Antimicrob Chemother 2007;59:11481154.
43. Capelastegui, A, Espana, PP, Quintana, JM, et al. Improvement of process-of-care and outcomes after implementing a guideline for the management of community-acquired pneumonia: a controlled before-and-after design study. Clin Infect Dis 2004;39:955963.
44. Mangino, JE, Peyrani, P, Ford, KD, et al. Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study. Crit Care 2011;15:R38.
45. McGregor, JC, Weeks, E, Forrest, GN, et al. Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial. J Am Med Inform Assoc 2006;13:378384.
46. Barenfanger, J, Short, MA, Groesch, AA. Improved antimicrobial interventions have benefits. J Clin Microbiol 2001;39(8):28232828.
47. Nowak, MA, Nelson, RE, Breidenbach, JL, Thompson, PA, Carson, PJ. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm 2012;69:15001508.
48. Yong, MK, Buising, KL, Cheng, AC, Thursky, KA. Improved susceptibility of gram-negative bacteria in an intensive care unit following implementation of a computerized antibiotic decision support system. J Antimicrob Chemother 2010;65;10621069.
49. Carratalà, J, Gardia-Vidal, C, Ortega, L, et al. Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia. Arch Intern Med 2012;172:922928.
50. Oosterheert, JJ, Bonten, MJM, Schneider, MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomized trial. BMJ 2006;333(7580):1193. doi:10.1136/bmj.38993.560984.BE.
51. Pulcini, C, Dellamonica, J, Bernardin, G, Molinari, N, Sotto, A. Impact of an intervention designed to improve the documentation of the reassessment of antibiotic therapies in an intensive care unit. Med Mal Infect 2011;546552.
52. Goldstein, EJC, Citron, DM, Peraino, V, Elgourt, T, Meibohm, AR, Lu, S. Introduction of ertapenem into a hospital formulary: effect on antimicrobial usage and improved in vitro susceptibility of Pseudomonas aeruginosa . Antimicrob Agents Chemother 2009;53:51225126.
53. Jensen, J, Hein, L, Lundgren, B, et al; Procalcitonin and Survival Study (PASS) Group. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med 2011;39:20482058.
54. Annane, D, Maxime, V, Faller, JP, et al. Procalcitonin levels to guide antibiotic therapy in adults with non-microbiologically proven apparent severe sepsis: a randomized controlled trial. BMJ Open 2013;3:e002186.
55. Agarwal, R, Schwartz, DN. Procalcitonin to guide duration of antimicrobial therapy in intensive care units: a systematic review. Clin Infect Dis 2011;53(4):379387.
56. Schuetz, P, Miller, B, Christ-Crain, M, Stoltz, D, Tamm, M, Bouadma, L. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract diseases. Cochrane Database Syst Rev 2012;9:CD007498. doi: 10.1002/14651858.CD007498.pub2.
57. Filice, GA, Drekonja, DM, Thurn, JR, et al. Use of a computer decision support system and antimicrobial therapy appropriateness. Infect Control Hosp Epidemiol 2013;34(6):558565.
58. Huttner, B, Jones, M, Rubin, MA, et al. Double trouble: how big is a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centers? J Antimicrob Chemother 2012;67:15371539.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed