Systematic review of implementing stewardship activities to promote appropriate antimicrobial use.

Objective: This systematic review aims to describe the impact of specific antimicrobial stewardship program (ASP) strategies on implementation and stewardship-related outcomes. Design: Systematic literature review. Methods: We systematically searched multiple databases using search terms that focused on stewardship and implementation. An original search was completed on October 29, 2021, and then updated on February 26, 2025. Studies were eligible for inclusion if they were in English, reported an antimicrobial resource outcome, and using either a comparison group or a pre/post design as a minimum level of rigor. Data from articles were extracted to understand the context and design of the evaluation, the types of approaches used, and outcomes assessed. Results: Out of 2035 studies that were identified, we included 250 full-text peer-reviewed manuscripts. Of the 250 studies included, 52% were conducted in the USA. The majority (80%) of studies were conducted in inpatient settings, particularly in adult academic hospitals (29%). Programs were often implemented hospital-wide or across multiple specialties, with a focus on emergency medicine and intensive care units. Education or learning (64% of studies) and handshake stewardship (56% of studies) were by far the most common ASP strategies used. Mortality (36% of studies) and drug choice (57% of studies) were the most tracked patient and resource outcomes, respectively. Conclusions: Our review highlights the variability in approaches as part of ASPs, indicating a need for a more systematic understanding of how different approaches are implemented and their subsequent impact on antimicrobial use.