Antibiotic stewardship programs reduce incidence of C. difficile, multidrug-resistant infections, review finds

The systematic review also found that antibiotic stewardship programs were significantly more effective when implemented along with infection control measures.


Hospitals that implemented antibiotic stewardship programs found many benefits, including a 51% reduction in the incidence of multidrug-resistant infections with gram-negative bacteria, according to a recent systematic review and meta-analysis.

Researchers assessed 32 studies conducted between 1992 and 2014 in 20 countries to evaluate the effect of stewardship programs on the incidence of infection and colonization with drug-resistant bacteria as well as Clostridium difficile infection in hospitalized patients (excluding those in long-term care facilities). The studies included more than nine million patient-days and 159 estimates of incidence ratios (IRs).

Primary outcomes were IRs of certain infections and colonization per 1,000 patient-days before and after implementation of a stewardship program. Results were published online on June 16 by The Lancet Infectious Diseases.

Overall, stewardship programs reduced the incidence of infections and colonization with multidrug-resistant gram-negative bacteria by 51% (IR, 0.49; 95% CI, 0.35 to 0.68; P<0.0001), with extended-spectrum beta-lactamase-producing gram-negative bacteria by 48% (IR, 0.52; 95% CI, 0.27 to 0.98; P=0.0428), and with methicillin-resistant Staphylococcus aureus by 37% (IR, 0.63; 95% CI, 0.45 to 0.88; P=0.0065).

Programs also reduced the incidence of C. difficile infections by 32% (IR, 0.68; 95% CI, 0.53 to 0.88; P=0.0029). However, they did not significantly affect the IRs of vancomycin-resistant enterococci and quinolone-resistant and aminoglycoside-resistant gram-negative or gram-positive bacteria.

Compared to stewardship programs implemented alone, those that were implemented with infection control measures were more effective (IR, 0.69; 95% CI, 0.54 to 0.88; P=0.0030), especially those that included hand-hygiene interventions (IR, 0.34; 95% CI, 0.21 to 0.54; P<0.0001). The effect of stewardship programs was particularly pronounced in hematology-oncology settings (IR, 0.41; 95% CI, 0.20 to 0.85; P=0.0166). Of the different stewardship programs, antibiotic cycling had the most significant effect (IR, 0.49; 95% CI, 0.34 to 0.72; P=0.0030), followed by audits and feedback (IR, 0.66; 95% CI, 0.52 to 0.83; P=0.0006) and antibiotic restriction (IR, 0.77; 95% CI, 0.67 to 0.89; P=0.0003).

The authors noted limitations of the analysis, including the low number of eligible studies (due to scarcity of essential data) and significant heterogeneity among the included studies.

An accompanying editorial noted that the meta-analysis results are an important advocacy tool for stewardship programs, which can decrease antibiotic resistance while preserving antibiotic effectiveness. “If we get antibiotic stewardship right, the real winner will be the patient who avoids infection by a drug-resistant bacterium or C difficile, now and in the future, as we preserve antibiotics for the generations to come,” the editorialists wrote.