Impact of a mixed educational and semi-restrictive antimicrobial stewardship project in a large teaching hospital in Northern Italy

Infection. 2017 Dec;45(6):849-856. doi: 10.1007/s15010-017-1063-7. Epub 2017 Aug 30.


Background: The overuse of antimicrobials favors the dissemination of antimicrobial resistance, as well as invasive fungal diseases and Clostridium difficile infections (CDI). In this study, we assessed the impact of a mixed educational and semi-restrictive antimicrobial stewardship (AMS) project in a large teaching hospital in Italy.

Methods: The AMS project was conducted from May 2014 to April 2016. It consisted of two initiatives in two consecutive periods: (1) educational activities; (2) semi-restrictive control of antimicrobial prescribing through a computerized software. The primary endpoint was consumption of antibacterials and antifungals. Secondary endpoints were incidence of CDI, methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI), carbapenem-resistant Klebsiella pneumoniae (CRKP) BSI, and Candida BSI.

Results: During the study period, a statistically significant reduction in consumption was observed for antibacterials (-1.45 defined daily doses (DDD)/1000 patient-days monthly, 95% confidence intervals [CI] -2.38 to -0.52, p 0.004), mainly driven by reductions in the use of fluoroquinolones, third/fourth generation cephalosporins, and carbapenems. No decrease in consumption of antifungals was observed (-0.04 DDD/1000 patient-days monthly, 95% CI -0.34 to +0.25, p 0.750). A statistically significant trend towards reduction was observed for incidence of CRKP BSI (incidence rate ratio 0.96, 95% CI 0.92-0.99, p 0.013). No statistically significant variations in trends were observed for CDI, MRSA BSI, and Candida BSI.

Conclusions: The mixed AMS project was effective in reducing the use of major antibacterials and the incidence of CRKP BSI. Further research is needed to assess the extent of long-term benefits of semi-restrictive approaches.

Keywords: Antibiotics; Antifungals; Antimicrobial resistance; Antimicrobial stewardship; CDI; CPE; CRE; Carbapenems; Clostridium; DDD; KPC; Klebsiella.

MeSH terms

  • Anti-Bacterial Agents / therapeutic use*
  • Antifungal Agents / therapeutic use*
  • Antimicrobial Stewardship / statistics & numerical data*
  • Bacteremia / epidemiology*
  • Candidiasis / blood
  • Candidiasis / epidemiology*
  • Hospitals, Teaching / statistics & numerical data*
  • Incidence
  • Italy / epidemiology


  • Anti-Bacterial Agents
  • Antifungal Agents