A systematic review of antimicrobial stewardship interventions implemented in intensive care units

Antimicrobial stewardship (AS) is essential to ensure appropriate antimicrobial usage and subsequently reduce the emergence of microbial resistance. The intensive care unit is a crucial place for monitoring antimicrobial usage due the frequent exposure to infections. This review provides an update on the current status of AS intervention utilized in intensive care settings. A comprehensive search was performed in Cochrane, Web of Science, and PubMed using keywords grouped into Antimicrobial, Stewardship, and Intensive care unit. The search was restricted to original articles published from April 2015 to November 2024. Of 1234 records retrieved from the databases, 55 studies were included in this systematic review. Most of the studies were conducted in the USA (N = 9), followed by China (N = 8), India (N = 5), and Italy (N = 4). We identified seven key AS strategies: multi-intervention AS programmes (22 studies, 40%), prospective feedback and audit (11 studies, 20%), procalcitonin (PCT) protocols for guiding antimicrobial use (12 studies, 21.8%), protocols for antimicrobial de-escalation (four studies, 7.3%), antimicrobial restrictions or preapprovals (four studies, 7.3%), diagnostic stewardship (one study, 1.8%), and guidelines for antimicrobial prescription (one study, 1.8%). A reduction in targeted or overall antimicrobial usage was reported in most studies (34/42). Specifically, all studies implementing multi-invention AS programmes reported a successful reduction in antimicrobial utilization. Some AS interventions significantly enhanced the appropriateness of antimicrobial prescriptions. In addition, patient health outcomes were not compromised by antimicrobial reduction. Nonetheless, future studies at a larger scale over a longer time are recommended to accurately assess the impact of AS programme on patient health outcomes.