A stepwise introduction of a successful antimicrobial stewardship program. Experience from a tertiary care university hospital in Western, Saudi Arabia

Maha M. Alawi, Bayan M. Darwesh


Objectives: To analyze and evaluate the safety and cost-effectiveness of a gradually-implemented antimicrobial stewardship programs (ASP) in a tertiary care center.

Methods: Prospective data were collected from an ASP that was gradually introduced between April 2012 and December 2013 in 6 hospital departments, over successive periods of 3 months each. A multidisciplinary team supervised antibiotic use and regulated pharmacy dispensations of a list of restricted antimicrobials (RAs). Indicators were prospectively monitored and included hospital mortality as the safety indicator; incidence of multi-drug resistance (MDR) infections as the effectiveness indicator, RA cost savings as the cost-effectiveness indicator and RA consumption indicated the process implementation.

Results: Between 2012 and 2014, dispensations of RAs decreased by 67% and prescriptions by 75%; no increase in mortality rate was observed. Microbiologically, there was a decreasing trend of incidence across all monitored infections, but this was only significant for Acinetobacter baumannii (p=0.007). Cost analysis showed a decrease in expenditure for RAs, with an average monthly saving of up to 326,020USD.

Conclusions: Stepwise implementation of ASPs is a safe and cost-effective strategy for improving antibiotic prescribing practice and to reduce multi-drug resistance. 


Saudi Med J 2016; Vol. 37 (12): 1350-1358
doi: 10.15537/smj.2016.12.15739


Antimicrobial stewardship program; antimicrobial resistance; multidrug resistance; misprescribing; misuse; overuse; broad-spectrum antimicrobial

Full Text:



Roque F, Herdeiro MT, Soares S, Teixeira Rodrigues A, Breitenfeld L, Figueiras A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014; 14: 1276.

Oldfield E, Feng X. Resistance-resistant antibiotics. Trends Pharmacol Sci [Internet] 2014; 35: 664-674.

Antimicrobial Review on Resistance. Antimicrobial resistance: Tackling a crisis for the health and wealth of nations [Internet]. London (UK): Wellcome Trust; 2014.

Lakshmana Gowda K, Marie MAM, Al-Sheikh YA, John J, Gopalkrishnan S, Chikkabidare Shashidhar P, et al. A 6-year surveillance of antimicrobial resistance patterns of Acinetobacter baumannii bacteremia isolates from a tertiary care hospital in Saudi Arabia during 2005-2010. Libyan J Med [Internet] 2014; 9: 24039.

Abdalhamid B, Hassan H, Itbaileh A, Shorman M. Characterization of carbapenem-resistant Acinetobacter baumannii clinical isolates in a tertiary care hospital in Saudi Arabia. New Microbiol [Internet] 2014; 37: 65-73.

Elabd FM, Al-Ayed MSZ, Asaad AM, Alsareii SA, Qureshi MA, Musa HAA. Molecular characterization of oxacillinases among carbapenem-resistant Acinetobacter baumannii nosocomial isolates in a Saudi hospital. J Infect Public Health 2015; (3): 242-247.

Al-Humaidan OS, El-Kersh TA, Al-Akeel RA. Risk factors of nasal carriage of Staphylococcus aureus and methicillin-resistant Staphylococcus aureus among health care staff in a teaching hospital in central Saudi Arabia. Saudi Med J 2015; 36: 1084-1090.

Harastani HH, Tokajian ST. Community-associated methicillin-resistant Staphylococcus aureus clonal complex 80 type IV (CC80-MRSA-IV) isolated from the Middle East: a heterogeneous expanding clonal lineage. PLoS One 2014; 9: e103715.

Monecke S, Skakni L, Hasan R, Ruppelt A, Ghazal SS, Hakawi A, et al. Characterisation of MRSA strains isolated from patients in a hospital in Riyadh, Kingdom of Saudi Arabia. BMC Microbiol 2012; 23: 146.

Tokajian S. New epidemiology of Staphylococcus aureus infections in the Middle East. Clinical Microbiology and Infection 2014; 20: 624-628.

Rahman BA, Wasfy MO, Maksoud MA, Hanna N, Dueger E, House B. Multi-drug resistance and reduced susceptibility to ciprofloxacin among Salmonella enterica serovar Typhi isolates from the Middle East and Central Asia. New Microbes New Infect 2014; 2: 88-92.

Vali L, Dashti AA, Jadaon MM, El-Shazly S. The emergence of plasmid mediated quinolone resistance qnrA2 in extended spectrum β-lactamase producing Klebsiella pneumoniae in the Middle East. Daru 2015; 23: 34.

Bertrand X, Dowzicky MJ. Antimicrobial susceptibility among gram-negative isolates collected from intensive care units in North America, Europe, the Asia-Pacific Rim, Latin America, the Middle East, and Africa between 2004 and 2009 as part of the tigecycline evaluation and survey. Clin Ther 2012; 34: 124-137.

Said KB, Al-Jarbou AN, Alrouji M, Al-Harbi HO. Surveillance of antimicrobial resistance among clinical isolates recovered from a tertiary care hospital in Al Qassim, Saudi Arabia. Int J Health Sci (Qassim) 2014; 8: 3-12.

Center for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2013. [cited 2016 Feb 8]. Available from: http://www.cdc.gov/drugresistance/threat-report-2013/index.html

European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2014. [cited 2016 Feb 8]. Available from: http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/graph_reports.aspx

van de Sande-Bruinsma N, Grundmann H, Verloo D, Tiemersma E, Monen J, Goossens H, et al. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis 2008; 14: 1722-1730.

Livermore DM. Minimising antibiotic resistance. Lancet Infect Dis 2005; 5: 450-459.

Dubourg G, Lagier JC, Armougom F, Robert C, Audoly G, Papazian L, et al. High-level colonisation of the human gut by Verrucomicrobia following broad-spectrum antibiotic treatment. Int J Antimicrob Agents 2013; 41: 149-155.

Panda S, El Khader I, Casellas F, López Vivancos J, García Cors M, Santiago A, et al. Short-term effect of antibiotics on human gut microbiota. PLoS One 2014; 9: e95476.

Mason KL, Erb Downward JR, Mason KD, Falkowski NR, Eaton KA, Kao JY, et al. Candida albicans and bacterial microbiota interactions in the cecum during recolonization following broad-spectrum antibiotic therapy. Infect Immun 2012; 80: 3371-3380.

NICE antimicrobial stewardship: right drug, dose, and time? Lancet 2015; 386: 717.

Spellberg B, Gilbert DN. The future of antibiotics and resistance: a tribute to a career of leadership by John Bartlett. Clin Infect Dis 2014; 59 Suppl 2: S71-S75.

Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159-177.

Aryee A, Price N. Antimicrobial stewardship - can we afford to do without it? Br J Clin Pharmacol 2015; 79: 173-181.

Mendelson M. Role of antibiotic stewardship in extending the age of modern medicine. S Afr Med J 2015; 105: 414-418.

Perez KK, Olsen RJ, Musick WL, Cernoch PL, Davis JR, Peterson LE, et al. Integrating rapid diagnostics and antimicrobial stewardship improves outcomes in patients with antibiotic-resistant Gram-negative bacteremia. J Infect 2014; 69: 216-225.

Viale P, Giannella M, Lewis R, Trecarichi EM, Petrosillo N, Tumbarello M. Predictors of mortality in multidrug-resistant Klebsiella pneumoniae bloodstream infections. Expert Rev Anti Infect Ther 2013; 11: 1053-1063.

Zilberberg MD, Shorr AF, Micek ST, Vazquez-Guillamet C, Kollef MH. Multi-drug resistance, inappropriate initial antibiotic therapy and mortality in Gram-negative severe sepsis and septic shock: a retrospective cohort study. Crit Care 2014; 18: 596.

Shorr AF, Zilberberg MD, Micek ST, Kollef MH. Predictors of hospital mortality among septic ICU patients with Acinetobacter spp. bacteremia: a cohort study. BMC Infect Dis 2014; 14: 572.

Patel SJ, Saiman L. Antibiotic resistance in neonatal intensive care unit pathogens: mechanisms, clinical impact, and prevention including antibiotic stewardship. Clin Perinatol 2010; 37: 547-563.

Shorman M, Al-Tawfiq JA. Risk factors associated with vancomycin-resistant enterococcus in intensive care unit settings in Saudi Arabia. Interdiscip Perspect Infect Dis 2013; 2013: 369674.

Katsios CM, Burry L, Nelson S, Jivraj T, Lapinsky SE, Wax RS, et al. An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients. Crit Care 2012; 16: R216.

Wenisch JM, Equiluz-Bruck S, Fudel M, Reiter I, Schmid A, Singer E, et al. Decreasing Clostridium difficile infections by an antimicrobial stewardship program that reduces moxifloxacin use. Antimicrob Agents Chemother 2014; 58: 5079-5083.

Schwartzberg E, Rubinovich S, Hassin D, Haspel J, Ben-Moshe A, Oren M, et al. Developing and implementing a model for changing physicians’ prescribing habits--the role of clinical pharmacy in leading the change. J Clin Pharm Ther 2006; 31: 179-185.

Jump RLP, Olds DM, Seifi N, Kypriotakis G, Jury LA, Peron EP, et al. Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012; 33: 1185-1192.

Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013; (4): CD003543.

Mack A, Relman DA, Choffnes ER. Antibiotic resistance: implications for global health and novel intervention strategies: workshop summary. Washington (DC): National Academies; 2010.

Srinivasan A, Song X, Richards A, Sinkowitz-Cochran R, Cardo D, Rand C. A survey of knowledge, attitudes, and beliefs of house staff physicians from various specialties concerning antimicrobial use and resistance. Arch Intern Med 2004; 164: 1451-1456.

Baadani AM, Baig K, Alfahad WA, Aldalbahi S, Omrani AS. Physicians’ knowledge, perceptions, and attitudes toward antimicrobial prescribing in Riyadh, Saudi Arabia. Saudi Med J 2015; 36: 613-619.

Al-Harthi SE, Khan LM, Osman A-MM, Alim MA, Saadah OI, Almohammadi AA, et al. Perceptions and knowledge regarding antimicrobial stewardship among clinicians in Jeddah, Saudi Arabia. Saudi Med J 2015; 36: 813-820.

Gonzalez-Gonzalez C, López-Vázquez P, Vázquez-Lago JM, Piñeiro-Lamas M, Herdeiro MT, Arzamendi PC, et al. Effect of Physicians’ Attitudes and Knowledge on the Quality of Antibiotic Prescription: A Cohort Study. PLoS One 2015; 10: e0141820.

Lopez-Vazquez P, Vazquez-Lago JM, Figueiras A. Misprescription of antibiotics in primary care: a critical systematic review of its determinants. J Eval Clin Pract 2012; 18: 473-484.

Pinder R, Sallis A, Berry D, Chadborn T. Behaviour change and antibiotic prescribing in healthcare settings. Literature review and behavioural analysis. Wellington House (UK): Public Health England; 2015.

Teixeira Rodrigues A, Ferreira M, Piñeiro-Lamas M, Falcão A, Figueiras A, Herdeiro MT. Determinants of physician antibiotic prescribing behaviour: a 3-year cohort study in Portugal. Curr Med Res Opin 2016; 32: 949-957.

Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. Crit Care 2014; 18: 480.

Rodrigues AT, Ferreira M, Roque F, Falcão A, Ramalheira E, Figueiras A, et al. Physicians’ attitudes and knowledge concerning antibiotic prescription and resistance: questionnaire development and reliability. BMC Infect Dis 2016; 16: 7.

Dallas A, van Driel M, van de Mortel T, Magin P. Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice. Br J Gen Pract 2014; 64: e561-e567.


  • There are currently no refbacks.

Saudi Medical Journal is copyright under the Berne Convention and the International Copyright Convention.  Saudi Medical Journal is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. Electronic ISSN 1658-3175. Print ISSN 0379-5284.