ImportanceAntimicrobial resistance continues to spread rapidly at a global scale. Little evidence exists on the association of antimicrobial stewardship programs (ASPs) with the consumption of antibiotics across health care and income settings.ObjectiveTo synthesize current evidence regarding the association between antimicrobial stewardship programs and the consumption of antibiotics globally.Data SourcesPubMed, Web of Science, and Scopus databases were searched from August 1, 2010, to Aug 1, 2020. Additional studies from the bibliography sections of previous systematic reviews were included.Study SelectionOriginal studies of the association of ASPs with antimicrobial consumption across health care and income settings. Animal and environmental studies were excluded.Data Extraction and SynthesisFollowing the Preferred Reporting Items in Systematic Reviews and Meta-Analyses guideline, the pooled association of targeted ASPs with antimicrobial consumption was measured using multilevel random-effects models. The Effective Public Health Practice Project quality assessment tool was used to assess study quality.Main Outcomes and MeasuresThe main outcome measures were proportion of patients receiving an antibiotic prescription and defined daily doses per 100 patient-days.ResultsOverall, 52 studies (with 1 794 889 participants) measured the association between ASPs and antimicrobial consumption and were included, with 40 studies conducted in high-income countries and 12 in low- and middle-income countries (LMICs). ASPs were associated with a 10% (95% CI, 4%-15%) reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption (rate ratio, 0.72; 95% CI, 0.56-0.92). ASPs were also associated with a 21% (95% CI, 5%-36%) reduction in antibiotic consumption in pediatric hospitals and a 28% reduction in World Health Organization watch groups antibiotics (rate ratio, 0.72; 95% CI, 0.56-0.92).Conclusions and RelevanceIn this systematic review and meta-analysis, ASPs appeared to be effective in reducing antibiotic consumption in both hospital and nonhospital settings. Impact assessment of ASPs in resource-limited settings remains scarce; further research is needed on how to best achieve reductions in antibiotic use in LMICs.

Background Antimicrobial resistance (AMR) constitutes a major threat to global health security. While antimicrobial misuse or overuse is a one of the main drivers for AMR, little is known regarding the extent to which this is due to a lack of national government-led efforts to enforce rational antimicrobial use in low and middle-income countries (LMICs). Methods To assess antimicrobial stewardship and national implementation measures currently in place for optimizing antimicrobial use and slowing the spread of AMR through expert’s lens, we invited public health experts from 138 LMICs to participate in a Global Survey of Experts on Antimicrobial Resistance (GSEAR). Key coverage measures as reported by experts were compared to across countries and also compared to estimates collected in the 2020-21 World Health Organization organized Tripartite AMR Country Self-assessment Survey (TrACSS). Results A total of 352 completed surveys from 118 LMICs were analysed. Experts in 67% of the surveyed countries reported a national action plan (NAP) on AMR, 64% reported legislative policies on antimicrobial use, 58% reported national training programs for health professionals, and 10% reported national monitoring systems for antimicrobials. 51% of LMICs had specific targeted policies to limit the sale and use of protected or reserve antibiotics. While 72% of LMICs had prescription requirements for accessing antibiotics, getting antibiotics without a prescription was reported to be possible in practice in 74% of LMICs. On average, country efforts reported in TrACSS were substantially higher than those seen in GSEAR. Conclusions Gaps in the implementation and enforcement of policies to reduce the risk of AMR in many LMICs remain large. Improved monitoring of national efforts as well as increased national efforts in the areas of enforcement and monitoring of antibiotic use are urgently needed to reduce inappropriate use and overuse in LMICs and to slow the spread of AMR globally.

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