Effective stewardship: less antibiotic use and more hand hygiene

Rossana Rosa (bio below) writes a guest post, reflecting on this recent review and meta-analysis on the effectiveness of antimicrobial stewardship (AMS) programmes…

The first reports on the effects of Antimicrobial Stewardship Programmess date back to the mid-90s, and the interest in them has taken off in the past decade.

Now, whether you have had to chase down your hospital’s leadership in order to start an AMS programme, or suddenly find yourself being asked to expand your AMS services (because of mandated government requirements), you have been confronted with questions like what type of interventions to include and what to measure to show for your work. On these topics, the recent meta-analysis by Baur et al provides some reassuring results (for a primer on the economic arguments for AMS programmes, see Nikky Naylor’s recent guest post).

The authors conducted a systematic literature view and meta-analysis of the effectiveness of AMS programmes in reducing the incidence of antibiotic-resistant bacterial infections and colonization. They searched articles dating back to Jan 1, 1960 up to May 31, 2016. They also collected information about the components of the AMS programmes, including whether infection control measures had been concomitantly implemented. Thirty-two articles were included in the meta-analysis.

What to measure? While each hospital will have its own MDR threat(s) to deal with, this study showed that AMS programs resulted in significant reductions in the incidence of MDR GNRs, ESBL producing GNRs, MRSA and C. diff.

Organism Incidence Rate Reduction p-value
MDR-Gram negative bacteria 0.49(0.35-0.68) <0.0001
ESBL-producing Gram negative bacteria 0.52(0.27-0.98) 0.0428
MRSA 0.63(0.45-0.88) 0.0065
C. difficile 0.68(0.53-0.88) 0.0029

What type of interventions to apply? AMS programs are frequently constrained by resources, but also by the “prescribing culture” at each facility. In that sense, it was encouraging to see that both “audit and feedback” as well as restriction are effective interventions.

Type of stewardship program Incidence rate reduction p-value
Antibiotic cycling 0.49(0.34-0.72) 0.0030
Audit and feedback 0.66(0.52-0.83) 0.0006
Antibiotic restriction 0.77(0.67-0.89) 0.0003
Use of implementing guidelines for antibiotic stewardship 1.03(0.85-1.25) 0.7946
Focusing on one antibiotic class 1.28(0.68-2.41) 0.4527

AMS + IPC. Ten of the 32 studies included in the meta-analysis reported on AMS programmes co-implemented with IC measures, most frequently hand hygiene and patient screening. In the studies with AMS+IPC, antibiotic resistance was reduced by 31% compared to 19% with AMS alone.  Programmes with AMS + hand hygiene saw a reduction in antibiotic resistance of 66% compared to 17% in those without a hand hygiene component.

This study gives excellent insights into what works in the inpatient setting. But as AMS programmes expand to outpatient clinics and Emergency Departments, it will be necessary to assess whether the strategies being applied in these setting are also yielding successful results.


Baur D, Gladstone BP, Burkert F, Carrara E, Foschi F, Döbele S, Tacconelli E.L Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. Lancet Infect Dis. 2017 Jun 16. doi: 10.1016/S1473-3099(17)30325-0. [Epub ahead of print]


Rossana Rosa (@a_thorny_rose) is an Infectious Diseases consultant based in Des Moines, Iowa.  Besides her clinical duties, she is also part of an Antimicrobial Stewardship Programme overseeing efforts across hospitals citywide, as well as in “outreach” locations across the state of Iowa. Rossana trained at Jackson Memorial Hospital -University of Miami in Florida. Her research interests have been focused on MDR Gram-negatives. Current interests include optimization of antibiotic use and syndrome based-testing and therapy.


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