TABLE 1

Individual studiesa

Study designation (reference)Pub yrMid-yrOriginStudy designASP typeDurationAntimicrobial restriction/control% changeAgeSetting
Amer MR (47)20132010Saudi ArabiaComparative historically controlled without intervention vs prospective arm under active ASPFormulary restriction; preapproval strategies (antimicrobial order forms); prospective audit and feedback; education; guidelines; pharmacodynamic dose optimization; antimicrobial cyclingPre-ASP: 6 mo (7–12/2009); ASP: started on 3/2011Piperacillin-tazobactam, imipenem, meropenem, vancomycin, tigecycline−0.84AdultsMedical 20-bed ICU (of 894-bed tertiary hospital)
Apasarthanarak A (48)20062004ThailandProspective cohort; pre-ASP vs prospective cohort; post-ASPEducation; feedback: bedside discussion; use of IV antibiotic prescription forms; use of antibiogram; computerized system recordingPre-ASP: 1 yr (7/2003–6/2004); post-ASP: 1 yr 7/2004–6/2005No−0.1365 ± 18 vs 66 ± 19350-bed tertiary care university hospital
Bantar C (35)20032000ArgentinaComparative historically controlled without intervention vs prospective arm under active ASPIntroduction of an optional, and later obligatory, antibiotic order form; feedback: bedside discussion toward modification of prescriptionPre-ASP: 6 mo (1– 6/1999); ASP: 2 yrs (6/1999–6/2001)No−0.36Adults250-bed public teaching hospital & 10-bed ICU
Borde JP 1 (39)20152012GernamyProspective cohort (pre- and post-ASP)Daily rounds; written pocket-sized; formats of guidelinesPre-ASP: >2 yrs (1/2011–3/2013); ASP: 4/2013; post-ASP: 1 yr (4/2013–3/2014)Third-generation cephalosporins, fluoroquinolones0.02NA200-bed community hospital and 10-bed ICU
Borde JP 2 (37)20142010GermanyProspective 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 auditPre-ASP: 3 yrs (1/2008–11/2011); ASP: 12/2011; post-ASP: >1 yr (1/2012–3/2013)Cephalosporins, fluoroquinolones−0.14NA300-bed medical service (of a 1,600 bed-academic teaching hospital)
Borde JP 3 (38)20152010GermanyProspective cohortGuideline revisions: written, pocket-sized formats and hospital intranet; information; education; intensified infectious diseases consultation and standardized treatment protocolPre-ASP: 3 yrs (1/2008–10/2011); ASP: 10/2011; post-ASP: >2 yrs (11/2011–10/2013)Cephalosporin (especially third generation) fluoroquinolones−0.07NAEmergency department −39-bed capacity (of a 1,600-bed academic teaching hospital)
Boyles TH (40)20132012Cape Town, South AfricaRetrospective cohort- control arm; prospective cohort-intervention armAntibiotic prescription chart; antibiotic stewardship ward rounds; audit of antibiotic prescription chart usePre-ASP: 1 yr (1–12/2011); ASP: 11/22/2011; post-ASP: 1 yr (1–12/2012)NA−0.248 ± 18 vs 50 ± 18Two 32-bed medical wards
Bozkurt F (49)20142013TurkeyCross-sectional study (before and after the interventionGuidelines; education (monthly seminars); feedback; audit of antimicrobial prescription in terms of duration and appropriateness of the treatmentASP: 5/16/2011–5/23/2015−0.33NA672-bed tertiary teaching and research hospital center with 6 ICUs, 10 medical and surgical units
Cisneros JM (29)20142011SpainProspective recorded interventionAntibiotic prescribers based on counseling interviews; guidelinesASP: 1–3/2011; post-ASP: 9–12/2011No−0.26NA1,251-bed tertiary care teaching hospital with 90 ICU beds and a transplant/BMT unit
Cook PP (30)20042001Louisville, KYRetrospective cohort- control arm; prospective cohort-intervention armEnhanced feedback after two preauthorization approvals for restricted antibiotics; treatment days for controlled antibioticsPre-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)−0.26Adults731-bed tertiary-care teaching hospital
Gould IM (41)20001994Scotland, United KingdomProspective cohort for both armsDrug restrictionPre-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, azithromycin0.17NAMulticenter: 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)20142011Taishan, ChinaRetrospective cohort- control arm; prospective cohort-intervention armFormulary restriction; preauthorization; educationPre-ASP: 6 mo (10/2010–3/2011); ASP: 4/2011–8/2011; post-ASP: 6 mo (10/2011–3/2012)Quinolones (perioperative use)−0.2753.10 ± 19.43 vs 54.59 ± 18.0712-bed ICU (700-bed tertiary hospital)
Kim YC (50)20132008South KoreaRetrospective cohort- control arm; prospective cohort-intervention armComputerized prescription restriction; formulary restriction; report outcomes of the ASPPre-ASP: 1 yr (2006); ASP: 8/2008 started; post-ASP: 1 yr (2011)Third-generation cephalosporin: surgery prophylaxis; aminoglycosides: surgery prophylaxis; inappropriate antibiotic combinations−0.13NA2,000-bed tertiary hospital
Lin YS (32)20132010Taipei, TaiwanRetrospective cohort- control arm; prospective cohort-intervention armFormulary, restriction; education concept; antibiotic stewardship, ward rounds: bedside evaluation, prospective audit, report outcomes of the program regularly to all staffPre-ASP: 6 mo (1–7/2009); ASP: 7/2009 introduced; post-ASP: 1 yr (7/2009–6/2012)Imipenem, meropenem, vancomycin, tigecycline, colistin, linezolid−0.21NA415-bed community public teaching hospital.
Mach R (42)20072002Czech RepublicProspective computerized surveyNew guidelines for antibiotic prophylaxis based on local microbial resistance patterns; prior authorization for the restricted antibioticsPre-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)−0.58NA500-bed general hospital
Meyer E (33)20072003GermanySegmented regression analysisRevised guidelines for pneumonia management; educationPre-ASP: 1 yr (2002–2003); ASP: January 2004 introduced; post-ASP: 1 yr (2005)No (revised guidelines: carbapenem removal for pneumonia)−0.34AdultsNeurosurgical 12-bed ICU
Ng CK (51)20082004Hong KongPretest/posttest analysisPolicy and guideline formulation; education; feedback; monthly antibiotic consumption; cost monitoring; antimicrobial susceptibility pattern reportingPre-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.−0.0671.4 ± 16.6 vs 72.9 ± 15.91,800-bed regional hospital providing acute care service
Nitsch-Osuch A 1 (43)20152013PolandRetrospective analysis before and after of ASP implementationWritten 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)0.050-18General pediatric 21-bed ward (of an academic hospital)
Nitsch-Osuch A 2 (44)20152012PolandRetrospective analysis before and after of ASP implementationPreauthorization approval of broad-spectrum antibioticsPre-ASP: 1 yr (2011); ASP: 2012 introduced; post-ASP: 1 yr (2012)Broad-spectrum antibiotics (e.g., glycopeptides and carbapenems)−0.31neonates10-bed special neonatal care units (of an academic hospital)
Niwa T (52)20122010JapanRetrospective cohort- control arm; prospective cohort-intervention armReview 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 informationPre-ASP: 1 yr (8/2008–7/2009); ASP: 2 yrs (8/2009–7/2011)No−0.0854 ± 22.5 vs 56 ± 22.6National 606-bed university hospital
Pate PG (36)20122010Dallas, TXRetrospective cohort- control arm; prospective cohort-intervention armProspective audit; ID consultationPre-ASP: <1 yr (1–11/2009); ASP: >1 yr (12/2009–2/2011)No−0.2167 (54–77) vs 68 (56–77)60-bed LTACH & 6-bed high-acuity patients
Peto Z (45)20082003HungarySegmented regression analysisICU/ID specialist consultant in rounds and over telephone; preauthorization approval on every antibiotic apart from antibiotics for surgical prophylaxisPre-ASP: (2 yrs) 2000–2002; ASP: 11/2002; post-ASP: (2 yrs) 2003–2005All apart from antibiotics for surgical prophylaxis−0.3856.3 ± 17.2 vs 56.8 ± 17.66-bed surgical ICU (of a university tertiary referral hospital)
Ruttimann S (46)20041998SwitzerlandQuasiexperimental studyPreauthorization approval for restricted drugs; educational program; written guidelinesPre-ASP: 1 yr (1996); ASP: 1997 introduced; post-ASP: 1 yr (2001)Ceftriaxone, ceftazidime, piperacillin-tazobactam, imipenem-cilastatin, vancomycin0.5Adults80-bed tertiary care center with 80 beds (including ICU)
Storey DF (34)20122010Dallas, TXRetrospective cohort- control arm; prospective cohort-intervention armASP team audited antimicrobial prescriptions provided nonbinding feedbackPre-ASP: 8 mo (1/2009–8/2009); ASP: 9–12/2009; post-ASP: >1 yr (9/2009–12/2010)No−0.1657.4 ± 18.6 vs 57.4 ± 18.743-bed medical-surgical services (24-bed medical-surgical wards, 11-bed; step-down unit and 8-bed ICU)
Yeo CL 1 (28)20122009SingaporeProspective interrupted time-series studyNon-binding prospective audit of antibiotic prescription with direct feedback via a written form for discontinuation, change or de-escalation; drug restrictionPre-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, vancomycin0.21AdultsNational university cancer institute (including BMT)
Yeo CL 2 (28)20122009SingaporeProspective interrupted time-series studyNonbinding prospective audit of antibiotic prescription with direct feedback via a written form for discontinuation, change, de-escalation, change route; drug restrictionPre-ASP: 1/8/2008–6/30/2009; ASP: 7/2009; post-ASP: 8/1/2009–6/30/2010Carbapenems; third-generation and fourth-generation cephalosporins, piperacillin-tazobactam, vancomycin0.29Adults990-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.