Cochrane systematic review on antimicrobial stewardship interventions. How do you see the glass?

By Bojana Beovic (ESGAP president)

The new Cochrane systematic review of interventions to improve antibiotic prescribing practices for hospital inpatients (see here) was published some weeks ago by Peter Davey and his group.  It is not an overstatement to say that antimicrobial stewardship community around the globe warmly welcomes one of the most comprehensive reviews on this topic, so far. The review represents a new tool for all those involved in antimicrobial stewardship clinical practice and education.  It will certainly be referenced in many educational presentations, papers and antimicrobial stewardship programmes in the hospitals.


In a few words, the review confirms the basic statement that antimicrobial stewardship interventions work, leading to better compliance with guidelines and shortened duration of antimicrobial treatments. This is relevant since adherence to guidelines has shown improved patient’s outcomes in many studies and because of the evidence that supports the harms of prolonged antimicrobial treatment.


We know more about the effective type of interventions: restriction should be combined with enablement, and enablement should (probably) include feedback. The positive role of enablement and feedback together with the negative professional culture through breakdown in trust and communication found in some studies on restrictive interventions speak for the utmost importance of communication skills for every antimicrobial steward.


For the non-believers, the review brings additional confirmation of the safety of antimicrobial stewardship interventions. Mortality was not increased, and there are just a few studies showing adverse effect of some specific interventions.


One major question remains open: do the interventions to improve antibiotic prescribing have an impact on antimicrobial resistance? The heterogeneity of the studies and the impact of setting and concomitant infection control activities make the conclusions regarding the antimicrobial resistance not possible.


The review clearly shows how much work has been done to improve antimicrobial prescribing world-wide, many studies have been done, and many papers published. Yet, if we look more closely at the figures: meta-analysis of the randomized controlled studies on adherence to guidelines only showed an increase from 43% to 58%! Assuming that adherence was even better than usual because of the study setting, the adherence even after the interventions remains strikingly low. Is it realistic to expect that improvement such as this one has an impact on better patient care?  What is the reason that at the same time the mankind produces high technology exactly as it should be produced and treats the patient following the gut feelings? Do we really, not only for statistical significance, do enough to contain antimicrobial resistance? Evidence on the impact of interventions on antimicrobial resistance, the major goal of antimicrobial stewardship, is not very firm. Are we going the wrong way or we are just too slow? Many difficult questions are still to be answered. Does the review leaves the glass half empty of half full?

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