Table 1 Findings of AMS interventions with their clinical, microbiological and prescription outcomes

Hall et al. [34]

Tanzania, Tertiary Care Hospital

Qualitative Study January 2017–December 2018

Adult medicine and paediatric wards

1. Baseline Clinician Survey on knowledge of AMS/AMR

2. Chart review of antimicrobial prescribing practices

3. Baseline audit of bacterial species and Antimicrobial Resistance Patterns

4. Local pharmacy survey Creating an AMS guidebook focused on the common organisms isolated in that location. Guidebook covering empirical antibiotic coverage based on resistance patterns, availability of the antibiotics and the national guidelines. Guidebook to be electronically distributed

Enabling

No outcome

Joshi et al. [27]

Nepal, Tertiary Care Hospital

Controlled Interrupted Time Series August 2016–August 2017

Adults over 15 years in medical, surgical and obstetric wards

1. Laboratory surveillance for baseline

2. Antibiotic prescribing guidelines based on common infections and drug availability

3. Post-prescription review and feedback adaptation led by physician champions in study wards, and stewardship training

4. Post-prescription review and feedback evaluation

Bundle: Persuasive and Enabling

1. Behavioral outcomes: (A) Recommendations by physician champions were most followed and in the medicine ward

2. Clinical outcomes: (A) DOT per 1,000 PD increased from 761 to 823 (P < 0.001) for intravenous therapy, and DOT for oral therapy increased from 302 to 390 (P < 0.001)

Cephalosporin use decreased from 420 DOT/1000 PD to 344 (P < 0.0001) and aminoglycoside decreased from 138 DOT/1000 PD to 95 (P < 0.001)

(B) No significant difference in length of stay

Gebretekle et al. [28]

Ethiopia, Tertiary care hospital

Controlled Interrupted Time Series November 17–January 2019

Adult medicine and paediatric wards

1. Adapting antimicrobial prescribing guidelines according to local common indications for antimicrobial prescription

2. Institutional microbiogram from laboratory data

3. Training pharmacists and giving AMR information sessions for clinicians

4. Pharmacists from the AMS issue a recommendation and followed up to assess acceptance or non-acceptance of the intervention

Bundle (Enabling and Persuasive)

1. Behavioral—Reduction in antibiotic prescription without documented source during post-intervention phase (25% vs. 16%)

2. Clinical: (A) Reduction in hospital acquired Infection (78% vs. 66%) (B) Days of Therapy: Days of antibiotic therapy increased: from 8.7 ± 6.9 days during the intervention, to 12.8 ± 11.7 days post intervention for all antibiotics. A twofold increase in DOT mean DOT of 754 ± 99.8/1000 patient-days in the intervention phase to 1549 ± 175.2/1000 patient-days during the following 5 months

(C) Length of Stay in hospital increased from 19.8 ± 12.0 days to 24.1 ± 13.9 (20% increase in duration, p < 0.001)

(D) All-cause mortality increased from 6.9% during the intervention to 14.7% post–intervention p < 0.01

Ackers et al. [31]

Uganda, Tertiary Care Hospital

Qualitative Study January 2019–January 2020

Obstetric patients

1. Four-month baseline data on drug orders and supplies from national medical stores and dispensing log

2. Introduction of swabbing post-caesarean wounds for laboratory diagnosis of infection (culture and sensitivity) and wound cleaning (Infection prevention)

3. Laboratory data on samples from post-natal ward

4. Survey on Perceptions of the impact and effectiveness of the AMS program

5. New policy to restrict high-end antibiotics culture and sensitivity indication

Structural and restrictive

1. Clinical: Increase in number and frequency of patient’s wounds being cleaned daily with culture and sensitivity from 0 to 95% of all suspected sepsis patients having culture and sensitivity

2. Behavioral: (A) Better patient care for women with septic wounds (B) Better collaboration among pharmacists, nurses and physicians in caring for patients

3. Procurement: Pharmacists became judicious in ordering of antibiotics using the information from the laboratory culture and sensitivity testing

Hearn et al. [29]

Cambodia, Hospital

Controlled Before and After January15–December 2015

Children

1. Pre-existing hospital antimicrobial guidelines were updated and converted into a free smartphone app

2. Pre-existing Point prevalence survey supported by a clinical microbiologist

Bundle: Enabling and Persuasive

1. Clinical: (A) Decrease in HAI incidence during surveillance period

(B) Median LOS for HAI cases increased for non-HAI controls: 25 days IQR 12–37 vs 5 days IQR 3–9

2. Microbiological: (A) 81% isolates were gram negative organisms. (B) Third generation cephalosporins were ineffective against 75% of clinical isolates

3. Behavioral: Increased use of guidelines in prescribing. 75.4% of antimicrobial prescriptions were appropriate

Gentilotti et al. [32]

Tanzania, Hospital

Controlled Before and After August 2013–August 2015

Obstetric Patients

1. Training in Antimicrobial resistance and appropriate prescribing

2. Developing an AMS multidisciplinary team to create and monitor AMS policies

Bundle: Enabling and Persuasive

1. Clinical: 65% reduction in CS SSIs

2. Microbiological: Lower SSI with Pfannenstiel incision (OR 0.288; 95% CI 0.197–0.420; p < 0.001) 2. Post-op antibiotic administration decreased post intervention

3. Behavioral—Increased use of skin disinfection. Improved adherence to standard operating procedures in the theatre

4. Microbiological: (A) Increased rate of microbiologically confirmed SSI was higher in post int group (OR 2.534; 95% CI 1.435–4.475; p = 0.001). (B) Decrease in prevalence of gram-positive SSI significantly decreased (OR 0.263; 95% CI 0.126–0.548; p < 0.001)

(C) Reduced MRSA prevalence (79–21.4% (OR 0.072; 95% CI 0.016–0.314; p < 0.001) (D) Increase in the prevalence gram-negative SSI (including Klebsiella and Pseudomonas.) (OR 3.800; 95% CI 1.822–7.926; p < 0.001)

Lester et al. [30]

Malawi, Tertiary hospital

Controlled before and after, Mixed methods study

Adults only

Pre-implementation prescribing survey

Antibiotic treatment guideline* booklet and app

Post-implementation prescribing surveys

Point-prevalence surveys with feedback to prescribers

Bundle, enabling and Persuasive

1. Clinical: 26.5% reduction in third generation cephalosporin use

2. Reduced treatment time for ceftriaxone from 5 to 4 days

3. No difference in mortality or length of stay

Nauriyal et al. [25]

Nepal, Three Hospitals

Controlled Before and After January 2018–January 2019

Adults with a burn or a wound (> 15 years)

1. Post prescription review and feedback program

2. Baseline and post-intervention chart review

Enabling

1. Decrease in days of therapy for penicillin, aminoglycosides, and cephalosporin

2. Decrease in days of therapy for intravenous antibiotics

3. Improved appropriate prescription, de-escalation, documentation, and adherence to treatment guidelines

Alabi et al. [33]

Liberia

Non-controlled before and after December 2019–December 2021

Adults and children

1. Microbiology laboratory for culture and sensitivity

2. Multidisciplinary AMS team

3. Treatment guideline, prescriber training and three weekly AMS ward rounds

Bundle: Enabling and Structural

1. Improved appropriate prescription

2. Challenges in adoption of prescribing guidelines: 39% in appropriate antibiotic chose, 63.5% had incorrect dose and 69% had incorrect duration

3. Use of microbiology laboratory for 79.7% of patients with infectious disease

Nelson et al. [26]

Bangladesh and Mali

Randomized cross over study. January 2021–November 2021

Children under 5 years

1. Development of diarrheal aetiology prediction algorithm

2. Physicians randomised to intervention and control arm

3. Study done at three sites in Bangladesh and 4 sites in Mali

Structural

1. No statistically significant difference in proportion of children prescribed antibiotics in intervention and control arm

2. No known adverse events from DEP tool