Behavior-change interventions to improve antimicrobial stewardship in human health, animal health, and livestock agriculture: A systematic review

Antimicrobial resistance (AMR) is an economic, food security, and global health threat that is driven by a multitude of factors including the overuse and misuse of antimicrobials in the human health, animal health, and agriculture sectors. Given the rapid emergence and spread of AMR and the relative lack of development of new antimicrobials or alternative therapies, there is a need to develop and implement non-pharmaceutical AMR mitigation policies and interventions that improve antimicrobial stewardship (AMS) practices across all sectors where antimicrobials are used. We conducted a systematic literature review per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify peer-reviewed studies that described behavior-change interventions that aimed to improve AMS and/or reduce inappropriate antimicrobial use in the human health, animal health, and livestock agriculture stakeholders. We identified 301 total publications - 11 in the animal health sector and 290 in the human health sector - and assessed these interventions using metrics across five thematic areas- (1) antimicrobial use (AMU), (2) adherence to clinical guidelines, (3) AMS, (4) AMR, and (5) clinical outcomes. The lack of studies in the animal health sector precluded a meta-analysis. Among studies in the human health sector, 35.7% reported significant (p<0.05) pre- to post-intervention decreases in AMU, 73.7% reported significant improvements in adherence of antimicrobial therapies to clinical guidelines, 45% demonstrated significant improvements in AMS practices, 45.5% reported significant decreases in the proportion of isolates that were resistant to antibiotics or the proportion of patients with drug-resistant infections across 17 antimicrobial-organism combinations, and few studies reported statistically significant changes in clinical outcomes. We did not identify any overarching intervention type nor characteristics associated with successful improvement in AMS, AMR, AMU, adherence, nor clinical outcomes.