Inclining Trend of the Researchers Interest in Antimicrobial Stewardship: A Systematic Review.

INTRODUCTION: The implementation of antibiotic stewardship programs (ASPs) can improve the treatment of infections and can decrease the adverse events that result from antibiotics use. In the last decades, there is an increasing interest of the researchers in the implementation of ASPs.
MATERIALS AND METHODS: The articles published in different journals were retrieved by searching many research databases such as Cochrane library, Europe PMC, PubMed, and Web of Science; we searched these databases for all published articles till November 2018. RESULTS AND DISCUSSION: The searching results using Cochrane library showed an increase in the number of randomized clinical trials that related to the keyword of "antimicrobial stewardship" specially in the last 5 years. Using Europe PMC, we found 6178 results. From these results, there are 3874 free full texts. In addition, there are 2132 original articles in PubMed and by searching Web of Science database till November 8 there are 3085 results. These results show that the number of trusted published articles was increased continuously; this shows the increasing interest of the researchers in ASPs. These researches will help health-care providers to use antibiotics appropriately and to overcome the barriers of implementing ASPs.
CONCLUSION: The results of this study show that the researchers had high levels of interest in participating in research activities related to the appropriate use on antibiotics and the implementation of antimicrobial stewardship programs. Copyright:

INTRODUCTION

Antibiotics have improved practice of medicine. They help in treating severe infections and augment advances in the medical field such as reducing likelihood of infections during organ transplants and cancer chemotherapy. The early initiation of antibiotics has been proven to decrease the mortality and morbidity rate of the infections, such as in the treatment of sepsis.[1] However, in acute care hospitals in the U.S. about 20%–50% of all antibiotic prescriptions either are not appropriate or are unnecessary.[234567]

One of the major problems that results from the inappropriate use of antibiotics is the emergence of antibiotic resistance, which is considered one of the serious threats to the public health.[8] According to the Centers for Disease Control and Prevention (CDC), it is estimated that more than 2 million people are infected with antibiotic-resistant organisms. This increase in the number of patients infected with antibiotic-resistant organisms results in high mortality rate annually (approximately 23,000 deaths each year).[9]

Nowadays, the improvement of antibiotic use is an important issue that affects the safety of the patient and the public health. Also it is considered as an important national priority.[10] The first educational effort was launched by CDC to improve the use of antibiotics in acute care hospitals in 2009.[11] The CDC in 2013 stated that there is a need for the improvement of antibiotic use. This improvement of antibiotic use is considered as an important strategy required to solve the problem of increasing emergence of antibiotic resistance problem in the U.S.[9]

The beginning of the implementation of hospital-based programs referred to as “antibiotic stewardship programs” (ASPs) can lead to positive outcomes. These programs improve the treatment of infections and decrease the adverse events that can be results from the use of antibiotics.[1213]

The implementation of these programs helps in improving the quality of care that will be given to the patient.[14] Moreover, this implementation results in improving the patient safety by increasing the cure rates of infections, decreasing the failures of the treatment, and increasing the rate of correct prescribing.[1516] They also decrease hospital rates of infections caused by clostridium difficile significantly[171819] and decrease the rate of antibiotic resistance.[2021] In addition to that, these programs also save the hospitals money.[22232425]

In the last decades, there is an increasing interest of the public, the health-care professionals, and the researchers in the use of antibiotics. As a part of that, there is an increasing interest in the implementation of antimicrobial stewardship programs.

The aim of this study was to show the increasing interest of the researchers in antimicrobial stewardship programs in recent years.

MATERIALS AND METHODS

The articles published in different journals were retrieved by searching many research databases such as Cochrane library,[26] Europe PMC,[27] PubMed,[28] and Web of Science.[29]

The principal parameters analyzed were the number of articles published in different databases, the comparison between different years regarding the number of the publications, the category of the publications, and the citation of publications.

The primary search used four major search engines. The first part contains the searching results using Cochrane library. The second part contains the searching results using Europe PMC. The third part contains the searching results using PubMed. The fourth part contains the searching results using Web of Science.

We include only articles related to antimicrobial stewardship; we excluded books, preprints, reviews, and clinical answers. The tables for the results were prepared using Microsoft Excel® 2016, Washington, US.

I review the CASP checklist[30] to make critical appraisal for the review articles. This checklist includes 10 questions in three main Sections.

Section A: Are the results of the study valid?

- I think the results of this review are valid because:

- The review addresses a clearly focused question.

- The right type of papers was looked for using original article from well-known secondary resources.

- I think that all of the important, relevant studies were included.

- The papers published in a well-known secondary resource that publishes papers with good quality.

- It reasonable to combine the results of the review.

Section B: What are the results?

The results showed that there is an increasing interest in antimicrobial stewardship program researches that will lead to the usage of antibiotics appropriately. The results were expressed by numbers and percentages.

Section C: Will the results help locally?

The results can be applied to the local population to improve the use of antibiotics. In addition, the review do not include any interventions so the benefits worth the harms and costs.

RESULTS

By searching Cochrane library in November 5, 2018, we included controlled trials and excluded reviews and clinical answers. Out of 134 searching results, there were 133 clinical trials. From these trials, 47 trials were added to central trial database in the last 2 years and 94 trials were added in the last 4 years.

Embase is the source of 78 antimicrobial stewardship trials in Cochrane library databases. The number of trials that were published in the last 5 years in Cochrane library database about antimicrobial stewardship is shown in Table 1.

Table 1

Searching Cochrane library about the antimicrobial stewardship trials

Year	No. of published study
2018	16
2017	31
2016	29
2015	18
2014	14

The second part comprised searching Europe PMC. Till November 15, we found 6178 results from these results and of these 3874 were free full-text articles. The year of the highest percentage was 2017; in this year there were 961 full-text articles published in Europe PMC database. Of these, 3874 were free full-text articles, and 3100 articles were published after 2013. The number of trials that were published in Europe PMC database about antimicrobial stewardship after 2013 is shown in Table 2.

Table 2

Searching Europe PMC about the antimicrobial stewardship publications

Year	No. of published study
2018	553
2017	961
2016	613
2015	518
2014	455

The third part comprised the results for searching PubMed. Since 1996 till November 15, 2018, there were 2853 articles in PubMed. These 2853 articles included 721 review articles, so after excluding the review articles the total number of original articles was 2132.

The year for the highest publications was 2018. From the beginning of 2018 till November 15, 2018, there were 586 original articles and 123 reviews in PubMed for “antimicrobial stewardship” keyword. Only 34 original researches were published before 2009. Table 3 represents the distribution of different searching results and the number of published articles about AS using PubMed.

Table 3

The number of the published articles about antimicrobial stewardship in PubMed since 1996

Year	No. of total publications in PubMed (articles and reviews)	No. of published articles in PubMed (excluding reviews)
1996	1	0
1997	2	0
1998	0	0
1999	1	1
2000	3	2
2001	0	0
2002	0	0
2003	4	1
2004	3	1
2005	7	3
2006	10	2
2007	17	12
2008	28	12
2009	37	23
2010	44	32
2011	88	55
2012	128	88
2013	179	134
2014	243	165
2015	290	213
2016	417	324
2017	642	478
2018 till November 15	709	586
Total	2853	2132

The fourth part comprised the results for searching Web of Science. Till November 8 there were 3085 results. Of these results 1275 were Open Access. After 2010, there were more than 100 publications each year. Since 2013 till November 8, 2018, there were 2567 publications (83.20%).

The main Web of Science categories are infectious diseases 1502 results and microbiology 802 results. The main document type is article (2134 of 3085). Table 4 represents the types of Web of Science documents.

Table 4

Web of science document types

Document types	Number of results
Article	2134
Review	471
Editorial material	198
Meeting abstract	130
Letter	121
Others	31

Of the 3085 results, there were 2134 original articles (including only original articles and excluding reviews, editorial materials, meeting abstracts, letters, and other documents).

DISCUSSION

There is an increasing interest of the researchers in antimicrobial stewardship programs. The results showed that there was an increase in the number of publications during the last several years.

In the first part “searching Cochrane library” in November 5, 2018, there were 133 trials matching on “antimicrobial stewardship” keyword. The majority of these trials published after 2013. This result showed that each year there was an increased number of publications related to antimicrobial stewardship especially in 2016 and 2017.

The second part included searching Europe PMC, and a total of 6178 results were found. The highest number on publications in 1 year was in 2017. Of 6178 articles, 961 were in 2017 (17.12%).

The third part included searching PubMed since 1996 till November 15, 2018. The results showed that there were 2853 published papers in PubMed. The number of publications increased continuously since 1996 (the first published article in 1996). The year for the highest publications is 2018. Till November 15, 2018, there were 586 original articles and 123 were reviews in PubMed for “antimicrobial stewardship” keyword.

After 2012 till November 15, 2018, the number of original articles that were published yearly is more than 100. For example, the number of publications (excluding reviews) in the last 7 years is 134 in 2013, 165 in 2014, 213 in 2015, 324 in 2016, 478 in 2017, and 586 in 2018.

In the fourth part, we used Web of Science to find the searching results for the keyword “antimicrobial stewardship,” we collected the data in November 8, 2018. Till November 8, there were 3085 results from different types. The results show that the number of publications are increasing continuously especially during the last several years. After 2010, there were more than 100 publications annually. Since 2013 till November 8, 2018, there were 2567 publications (83.20% of the publications were published after 2012).

The main Web of Science categories for our research are infectious diseases, microbiology, pharmacy/pharmacology, public environmental occupational health, and immunology. The majority of these publications were original articles (69.17 %) followed by review articles (15.26%).

The number of citations for 37 articles was more than 100 times. One of the publications (Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship) was cited 1571 times. This shows the importance of the appropriate use of antibiotics by implementing antimicrobial stewardship programs. In addition, this also shows the importance of continuous research activities that are related to these programs to help in optimizing the use of antibiotics

These results show that the health-care providers are interested in implementing antimicrobial stewardship programs and the researchers are interested in studying these programs to improve ASP implementation and to decrease the gaps and barriers for its implementation

CONCLUSION

There is an increasing interest in ASP researches, especially during the last several years. The results of this review study show that the researchers had high level of interest in the participation in research activities related to the appropriate use of antibiotics and the implementation of antimicrobial stewardship programs. This interest is very important to help the health-care providers in prescribing and dispensing antibiotic correctly and to solve the problem of antimicrobial resistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.