Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.
Unit of Internal Medicine and Infectious Diseases, University Hospital Antwerp, Antwerp, Belgium.
Bull World Health Organ. 2018 Apr 1;96(4):266-280. doi: 10.2471/BLT.17.203448. Epub 2018 Feb 28.
To review the effectiveness of antibiotic stewardship interventions in hospitals in low- and middle-income countries.
We searched MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials and regional indexes for studies of interventions to improve appropriate prescribing and use of antibiotics for hospitalized patients in low- and middle-income countries. We included controlled trials, controlled before-and-after studies and interrupted time-series studies published up to December 2017. We report prescribing, clinical and microbiological outcomes using a narrative approach.
We screened 7342 original titles and abstracts, assessed 241 full-text articles and included 27 studies from 2 low-income and 11 middle-income countries. We found a medium (11 studies) or high risk (13 studies) of bias. Generally, all types of interventions (structural, persuasive and enabling) and intervention bundles were reported to improve prescribing and clinical outcomes. However, the studied interventions and reported outcomes varied widely. The most frequent intervention was procalcitonin-guided antibiotic treatment (8 of 27 studies, all randomized controlled trials). The intervention was associated with a relative risk for patients receiving antibiotics ranging between 0.40 and 0.87.
The majority of studies reported a positive effect of hospital antibiotic stewardship interventions. However, we cannot draw general conclusions about the effectiveness of such interventions in low- and middle-income countries because of low study quality, heterogeneity of interventions and outcomes, and under-representation of certain settings. To strengthen the evidence base, action needs to be taken to address these shortcomings.
评价中低收入国家医院抗生素管理干预措施的效果。
我们检索了 MEDLINE、Embase、Cochrane 对照试验中心注册库和区域索引，以获取改善中低收入国家住院患者抗生素合理处方和使用的干预措施研究。我们纳入了对照试验、对照前后研究和中断时间序列研究，这些研究的发表时间截至 2017 年 12 月。我们采用叙述性方法报告处方、临床和微生物学结局。
我们筛选了 7342 篇原始标题和摘要，评估了 241 篇全文文章，纳入了来自 2 个低收入国家和 11 个中等收入国家的 27 项研究。我们发现偏倚风险为中等（11 项研究）或高（13 项研究）。一般来说，所有类型的干预措施（结构、劝导和支持）和干预措施组合都被报道能改善处方和临床结局。然而，所研究的干预措施和报告的结局差异很大。最常见的干预措施是降钙素原指导的抗生素治疗（27 项研究中的 8 项，均为随机对照试验）。该干预措施与抗生素治疗患者的相对风险比介于 0.40 和 0.87 之间。
大多数研究报告了医院抗生素管理干预措施的积极效果。然而，由于研究质量低、干预措施和结局存在异质性以及某些环境代表性不足，我们无法就此类干预措施在中低收入国家的有效性得出一般性结论。为了加强证据基础，需要采取行动解决这些缺陷。
