Research in context
Evidence before this study
We searched the Cochrane Database of Systematic Reviews and PubMed for studies on antimicrobial stewardship in the community setting published before March 1, 2019, using the search terms “antimicrobial stewardship”, “antibiotic stewardship”, or “stewardship program”, in addition to the terms “primary care”, “community care”, “ambulatory care”, “antimicrobial resistance”, and “extended-spectrum-beta-lactamase-producing Escherichia coli”, with no date or language restrictions. We reviewed guidelines on antimicrobial stewardship programmes (ASPs) published by relevant international scientific societies. We retrieved additional publications from the authors' personal reference lists and the reference lists of included studies. We identified three systematic reviews pooling the evidence provided by these studies. In these studies, we found that the evidence on the efficacy of ASPs in primary care for improving antibiotic use was considered low to moderate. In addition, information about the association of key intervention components with improved prescribing and about the efficacy of educational interventions in changing clinicians' prescribing behaviour was scarce, as were data on the sustainability and large-scale applicability of ASPs in health-care systems at the community level. Most studies focused exclusively on respiratory tract infections, with little information about the effectiveness of ASPs in other infections. In particular, urinary tract infections, which are commonly misdiagnosed and overtreated, were underrepresented. There was also a paucity of studies designed to assess the ecological effect of ASPs in the community, with a very low level of evidence on substantial or persistent reductions in the incidence of resistant bacteria, including E coli producing extended-spectrum β-lactamase.
Added value of this study
Our study supports the efficacy of ASPs in primary care to improve antibiotic use and associated ecological effects, such as reducing urinary tract infections caused by E coli producing extended-spectrum β-lactamases. It reinforces the value of educational interventions in increasing adherence to reference guidelines and change the prescribing behaviour of clinicians, and, to our knowledge, includes for the first time regular one-to-one educational interviews as the core activity of an ASP. The programme and its findings are sustainable over time and enforceable in health-care systems at the community level.
Implications of all the available evidence
Our findings suggest that multimodal educational ASPs based on peer-to-peer educational interviews can be useful to improve the use of antimicrobials and reduce bacterial resistance in the community, and that these changes can be sustained over time. This information reinforces the recommendations to implement ASPs in primary care and should encourage further studies to confirm the usefulness of individual educational interviews.