Introduction
Antimicrobial resistance (AMR) remains a pressing global health challenge, with the WHO Eastern Mediterranean Region (EMRO) facing unique burdens related to antibiotic use, stewardship implementation, and monitoring. This scoping review synthesizes the evidence on antimicrobial stewardship (AMS) interventions in EMRO countries, focusing on three core domains: clinical outcomes, economic implications, and antibiotic consumption patterns. By mapping the range of interventions and their effects, the review aims to guide policymakers, clinicians, and researchers toward effective, contextually appropriate AMS strategies.
Scope and Methods
The review systematically searched major databases to identify studies evaluating AMS interventions in EMRO countries. Eligible studies encompassed hospital- and community-based programs, stewardship education, guideline implementation, audit and feedback, formulary restrictions, rapid diagnostic tests, and multidisciplinary stewardship teams. Outcomes were categorized into clinical (patient health, mortality, infection cure rates), economic (costs, length of stay, resource utilization), and consumption metrics (antibiotic prescribing rates, defined daily doses, spectrum of activity). Studies spanning varying healthcare settings and geographies within EMRO were included to capture regional diversity in health systems and resource availability.
Clinical Outcomes of AMS Interventions
Across EMRO settings, AMS initiatives frequently reported improvements in clinical outcomes. Key findings include reductions in inappropriate antibiotic use and more guideline-concordant prescribing. Some studies noted decreases in infection-related complications and mortality, particularly when stewardship teams combined audit and feedback with education and guideline optimization. The integration of rapid diagnostic testing alongside stewardship activities showed potential for faster targeted therapy, shorter courses, and reduced broad-spectrum exposure. Importantly, the effectiveness of clinical outcomes often correlated with multifaceted approaches that engaged clinicians, pharmacists, microbiologists, and hospital leadership, reinforcing the need for institutional commitment to sustain gains.
Common clinical indicators observed
- Increased adherence to evidence-based guidelines
- Reduced inappropriate broad-spectrum antibiotic use
- Shorter duration of therapy in select infections
- Lower rates of antibiotic resistance development in targeted wards
Economic Implications of AMS Interventions
Economic evaluations within EMRO studies indicate that AMS programs can be cost-effective, particularly when they prevent adverse drug events, reduce unnecessary antibiotic consumption, and shorten hospital stays. Some analyses demonstrated net savings through optimized antibiotic dosing and reduced use of expensive broad-spectrum agents. However, economic evidence is heterogeneous, with variability driven by differences in health system financing, antibiotic pricing, and the scale of stewardship activities. Longitudinal economic assessments are limited in several EMRO countries, underscoring the need for standardized costing frameworks to enable cross-country comparisons and policy planning.
Key economic considerations
- Cost savings from reduced antibiotic utilization and streamlined therapy
- Impact on length of stay and resource use
- Return on investment linked to stewardship team infrastructure and education efforts
Antibiotic Consumption Patterns
Consumption metrics reveal a meaningful shift toward more rational antibiotic use following AMS interventions. Studies report reductions in defined daily doses (DDD) per 1,000 patient-days and a narrowing of antibiotic spectra where stewardship guidance emphasized first-line agents and de-escalation strategies. The use of broad-spectrum agents, such as carbapenems and third-generation cephalosporins, declined in several institutions, accompanied by increased adherence to local antibiograms and stewardship policies. Nevertheless, heterogeneity persists, with some settings showing limited or uneven adoption of stewardship principles due to resource constraints, staffing shortages, or gaps in surveillance data.
Patterns that supported consumption improvements
- Development of local guidelines aligned with national policies
- Regular audit-and-feedback cycles
- Access to microbiology data and timely susceptibility information
Gaps, Barriers, and Opportunities
Despite positive trends, several barriers limit AMS effectiveness in EMRO countries, including insufficient funding, limited laboratory capacity, and fragmented health information systems. Training and retaining skilled personnel for stewardship roles remain critical, as does the integration of AMS into broader infection prevention programs. Future work should emphasize standardized outcome reporting, harmonized economic evaluations, and tailored strategies that reflect the diversity of health systems within EMRO. Emphasis on regional collaboration, data sharing, and capacity building can accelerate improvements and ensure sustainable stewardship gains.
Conclusion
Antimicrobial stewardship interventions in the WHO Eastern Mediterranean Region show promise across clinical, economic, and consumption outcomes. Multifaceted programs that combine guideline-concordant prescribing, audit and feedback, rapid diagnostics, and leadership support tend to yield the strongest benefits. To maximize impact, EMRO countries should invest in surveillance infrastructure, human resources for stewardship, and standardized evaluation frameworks that enable cross-country learning and sustained improvements in antimicrobial use and patient outcomes.
