Hospital antibiotic stewardship interventions in low and middle income countries: A systematic review and meta-analysis

Document Type : Systematic review or meta-analysis


Medical Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt


Background: In low-and middle-income countries (LMICs), infectious diseases burden and increased rates of antimicrobial use, make the implementation of antimicrobial stewardship (AS) an indispensable choice. The study aimed to demonstrate the characteristics of AS interventions and to assess their impact on antibiotic, economic and clinical outcomes among hospitalized patients in LMICs. Methods: data from studies reporting the efficacy of hospital AS interventions and their impact on antibiotic, economic and/or clinical outcomes across LMICs were collected and interpreted. The data from the same outcomes were pooled and analysed using a random-effects meta-analysis model. Results: The antimicrobial consumption showed a 14.8% reduction (95% CI: 3.02 to 1.82, I2: 94.8%, p < 0.001). No evidence of small-study effect across studies was detected (Egger’s regression: 3.2, p-value 2-tailed: 0.12). The antimicrobial consumption was decreased by 1.1% (95% CI: 1.34 to 0.54, I2: 97.3%, p < 0.001). The implementation of AS has led to decrease in antimicrobial cost of 2.4% (95% CI: 1.47 to 1.27, I2: 92.6%, p < 0.001). The mean hospital length of stay was reduced by 19.1% (95% CI: 5.99 to 0.61, I2: 97.7%, p < 0.001). Conclusion: All the investigated interventions succeeded to positively affect the targeted outcomes.  Education was not underscored as an AS intervention, with complete absence of behavioural elements. Antimicrobial exposure/use/consumption is the most commonly used outcome indicator. For economic and LoS concerned studies, more data is needed to provide a stronger business case to encourage investing in AS. Limited data on AS interventions in LMICs entails urgent attention. 


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