Antimicrobial Stewardship in Transplant Recipients: A Scoping Review of Interventions, Outcomes, and Policy Implications.

Objective: This scoping review aimed to characterize antimicrobial stewardship (AMS) interventions in transplant recipients, compare antibacterial, antifungal, and antiviral stewardship strategies, summarize clinical and economic outcomes, and identify knowledge gaps relevant to health policy. Materials and Methods: The study was conducted according to the Joanna Briggs Institute methodology and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Original research articles published between January 2015 and March 2025 were identified through searches of the PubMed, Scopus, and Web of Science databases. Data were synthesized using thematic analysis. Results: Fifteen studies published between 2017 and 2025 were included. Thematic analysis categorized the interventions into the following domains: intervention structure, individualized strategies, diagnostic management, clinical and economic outcomes, comparative findings by population and transplant type, and implementation barriers. All studies included an antibacterial stewardship component (100%), whereas antifungal (20%) and antiviral (7%) interventions were comparatively limited. Interventions were primarily implemented as guideline-based optimization and prospective audit-and-feedback models. Infectious disease specialists participated in 87% of the studies, while clinical pharmacists were involved in 33%. Clinical effects were predominantly reported using process indicators. A reduction in antimicrobial treatment duration (47%) and improved guideline adherence (33%) were the most frequently reported outcomes. Studies evaluating mortality and graft survival were limited (27%), and most did not demonstrate significant differences. Economic outcomes were reported in 73% of the studies, with program-level cost reductions ranging from 20% to 40%. The most common implementation barriers were high resource requirements and heterogeneity of guidelines. Conclusion: Antimicrobial stewardship practices in transplant recipients are primarily focused on antibacterial management and are associated with improvements in short-term process indicators. However, evidence regarding long-term clinical outcomes and antifungal and antiviral stewardship practices remains limited. Developing transplant-specific, multidisciplinary, and sustainable AMS models is essential for antimicrobial resistance control and patient safety in this high-risk population.