Programs for optimizing the use of antibiotics and their implementation in low- and middle-income countries: A scoping review of methods and reported outcomes

Abstract

Objectives: To synthesize existing evidence on programs for optimizing the use of antibiotics, focusing on their implementation methods and reported outcomes in low- and middle-income countries (LMICs).

Study design: Scoping review following the PCC framework, JBI and PRISMA-ScR guidelines.

Methods: We searched MEDLINE, EMBASE, CENTRAL, Global Index Medicus, and two clinical trials registries. We included cross-sectional, cohort studies, quasi-experimental studies, and randomized controlled trials involving hospitalized patients of any age receiving oral or parenteral antibiotics. Eligible studies assessed the impact of antimicrobial stewardships programs (ASP) on outcomes such as antibiotic use and/or antimicrobial resistance, and were conducted in medium- or high-complexity healthcare settings in LMICs.

Results: We included 132 studies (134 references), predominantly from India (20.2%), Brazil (11.6%), and China (7.0%), 88.6% were published between 2018 and 2024, and median sample size was 491 participants. Studies were conducted across 30 different LMICs, primarily in upper-middle-income countries. The majority were quasi-experimental studies (62.1%) and focused on adult populations in public healthcare settings. Most studies (91.0%) labelled interventions as ASP. Reported outcomes included antimicrobial use (68.0%), patient or microbiological outcomes (68.0%), and process measures (66.0%). Common indicators were defined daily dose (DDD) per 100 patient-days (45.5%), in-hospital mortality (40.2%), and guideline compliance (35.6%).

Conclusions: ASP are increasingly implemented in LMICs, mainly in upper-middle-income countries and public healthcare settings, with most studies being quasi-experimental and from a few countries. Although antibiotic use, clinical outcomes, and process measures are commonly reported, significant variability persists in terminology, methods, and geographic representation. Standardized frameworks and expanded implementation are needed to improve evidence and inform policy.

Keywords: Antimicrobial stewardship programs; Antimicrobial use; Global health; Low- and middle-income countries; Rational antibiotic use; Systematic review.