Cited by 199Antibiotic Use and ResistanceSurgical site infection preventionAntibiotic Resistance in Bacteria

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Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

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Donà, D., Barbieri, E., Daverio, M., Lundin, R., Giaquinto, C., Zaoutis, T., Sharland, M.·2020·Antimicrobial Resistance & Infection Control

DOI 10.1186/s13756-019-0659-3PMC PMC6942341

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Abstract Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0–18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

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Fig. 1 Flowchart of the study selection processCC BY · PubMed Central

Fig. 2 Area cartogram of the world with each country rescaled in proportion to number of study included in this review (R version 3.5.3)CC BY · PubMed Central

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Effectiveness of Antimicrobial Guidelines for Community-Acquired Pneumonia in Children
Smith, M. J., Kong, M., Cambon, A. C., & Woods, C. R. (2012) · PEDIATRICS · doi:10.1542/peds.2011-2412 · Cited by 58
A point prevalence survey of hospital-acquired infections and antimicrobial use in a paediatric hospital in north-western Russia
Hajdu, Á., Samodova, O. V., Carlsson, T. R., Voinova, L. V., Nazarenko, S. J., Тюриков, А. В., Петрова, Е. Г., Tulisov, A., Andresen, S., & Eriksen, H. M. (2007) · Journal of Hospital Infection · doi:10.1016/j.jhin.2007.04.018 · Cited by 57
Antibiotic Stewardship in the Neonatal Intensive Care Unit: Effects of an Automatic 48-Hour Antibiotic Stop Order on Antibiotic Use
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Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection
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Successful introduction and audit of a step-down oral antibiotic strategy for low risk paediatric febrile neutropaenia in a UK, multicentre, shared care setting
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Demonstrating the Value of Antimicrobial Stewardship Programs to Hospital Administrators
Nagel, J. L., Stevenson, J. G., Eiland, E. H., & Kaye, K. S. (2014) · Clinical Infectious Diseases · doi:10.1093/cid/ciu566 · Cited by 51
Improvement of antibiotic prescription in outpatient care: a cluster-randomized intervention study using a sentinel surveillance network of physicians
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Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network
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Antimicrobial stewardship in the neonatal unit reduces antibiotic exposure
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Improving pneumonia case-management in Benin: a randomized trial of a multi-faceted intervention to support health worker adherence to Integrated Management of Childhood Illness guidelines
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Restriction of cephalosporins and control of extended spectrum β-lactamase producing gram negative bacteria in a neonatal intensive care unit
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Antibiotic prescriptions in acute otitis media and pharyngitis in Italian pediatric outpatients
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Physician Responses to a Community-Level Trial Promoting Judicious Antibiotic Use
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Antibiotic stewardship in the newborn surgical patient: A quality improvement project in the neonatal intensive care unit
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Effects of clinical pathway implementation on antibiotic prescriptions for pediatric community-acquired pneumonia
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Impact of pharmacist-led antibiotic stewardship program in a PICU of low/middle-income country
Haque, A., Hussain, K., Ibrahim, R., Abbas, Q., Ahmed, S. T., Jurair, H., & Ali, A. (2018) · BMJ Open Quality · doi:10.1136/bmjoq-2017-000180 · Cited by 39
Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative
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Effectiveness of an educational intervention to improve antibiotic dispensing practices for acute respiratory illness among drug sellers in pharmacies, a pilot study in Bangladesh
Chowdhury, F., Sturm-Ramirez, K. M., Mamun, A. A., Iuliano, A. D., Chisti, M. J., Ahmed, M., Bhuiyan, M. U., Hossain, K., Haider, M. S., Aziz, S. A., et al. (2018) · BMC Health Services Research · doi:10.1186/s12913-018-3486-y · Cited by 39
Adherence to surgical antibiotic prophylaxis remains a challenge despite multifaceted interventions
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Impact of an Antimicrobial Stewardship Program on the Use of Carbapenems in a Tertiary Women's and Children's Hospital, Singapore
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Impact of Matrix-Assisted Laser Desorption and Ionization Time-of-Flight and Antimicrobial Stewardship Intervention on Treatment of Bloodstream Infections in Hospitalized Children
Malcolmson, C., Ng, K., Hughes, S., Kissoon, N. “., Schina, J., Tilley, P. A. G., & Roberts, A. D. (2016) · Journal of the Pediatric Infectious Diseases Society · doi:10.1093/jpids/piw033 · Cited by 38
Implementation and Evaluation of the Early-Onset Sepsis Risk Calculator in a High-Risk University Nursery
Beavers, J., Bai, S., Perry, J., Simpson, J., & Peeples, S. E. (2017) · Clinical Pediatrics · doi:10.1177/0009922817751337 · Cited by 38
Decreasing vancomycin utilization in a neonatal intensive care unit
Holzmann-Pazgal, G., Khan, A. M., Northrup, T. F., Domonoske, C., & Eichenwald, E. C. (2015) · American Journal of Infection Control · doi:10.1016/j.ajic.2015.06.028 · Cited by 37
Impact of Antimicrobial Stewardship for Pediatric Outpatient Parenteral Antibiotic Therapy
Hersh, A. L., Olson, J. A., Stockmann, C. R., Thorell, E. A., Knackstedt, E. D., Esquibel, L., Sanderson, S. K., & Pavia, A. T. (2017) · Journal of the Pediatric Infectious Diseases Society · doi:10.1093/jpids/pix038 · Cited by 37
Implementation of an Automatic Stop Order and Initial Antibiotic Exposure in Very Low Birth Weight Infants
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The Impact of Pediatric-Specific Vancomycin Dosing Guidelines: A Quality Improvement Initiative
Miloslavsky, M., Galler, M. F., Moawad, I., Actis, J., Cummings, B., & Saleeby, C. M. E. (2017) · PEDIATRICS · doi:10.1542/peds.2016-2423 · Cited by 36
The North Wind and the Sun: Pediatric Antimicrobial Stewardship Program Combining Restrictive and Persuasive Approaches in Hematology-Oncology Ward and Hematopoietic Stem Cell Transplant Unit
Horikoshi, Y., Kaneko, T., Morikawa, Y., Isogai, M., Suwa, J., Higuchi, H., Yuza, Y., Shoji, T., & Ito, K. (2017) · The Pediatric Infectious Disease Journal · doi:10.1097/inf.0000000000001746 · Cited by 36
Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU
Cato, K., Sheehan, B., Patel, S. J., Duchon, J. M., DeLaMora, P. A., Ferng, Y., Graham, P., Vawdrey, D. K., Perlman, J. M., Larson, E., et al. (2014) · Applied Clinical Informatics · doi:10.4338/aci-2013-09-ra-0069 · Cited by 35
Influencing the use of antibiotics in a Chinese pediatric intensive care unit
Ding, H., Yang, Y., Wei, J., Fan, S., Yu, S., Yao, K., Wang, A., & Shen, X. (2008) · Pharmacy World & Science · doi:10.1007/s11096-008-9220-9 · Cited by 35
Use of Antimicrobial Agents for Community-Acquired Lower Respiratory Tract Infections in Hospitalised Children
Esposito, S., Blasi, F., Allegra, L., Principi, N., & The Mowgli Study Group (2001) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s100960100570 · Cited by 34
The Impact of Clinical Pathways on Antibiotic Prescribing for Acute Otitis Media and Pharyngitis in the Emergency Department
Donà, D., Baraldi, M., Brigadoi, G., Lundin, R., Perilongo, G., Hamdy, R. F., Zaoutis, T. E., Dalt, L. D., & Giaquinto, C. (2018) · The Pediatric Infectious Disease Journal · doi:10.1097/inf.0000000000001976 · Cited by 34
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Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources
Stocker, M., Ferrao, E., BANYA, W. A. S., Cheong, J., Macrae, D. J., & Furck, A. (2012) · BMC Pediatrics · doi:10.1186/1471-2431-12-196 · Cited by 33
Impact of an Educational Intervention to Improve Antibiotic Prescribing for Nurse Practitioners in a Pediatric Urgent Care Center
Weddle, G., Goldman, J. L., Myers, A., & Newland, J. G. (2016) · Journal of Pediatric Health Care · doi:10.1016/j.pedhc.2016.07.005 · Cited by 32
Impact of an Antimicrobial Stewardship Program on Antibiotic Use at a Nonfreestanding Children's Hospital
Turner, R. B., Valcarlos, E., Loeffler, A. M., Gilbert, M. J., & Chan, D. (2016) · Journal of the Pediatric Infectious Diseases Society · doi:10.1093/jpids/piw059 · Cited by 32
Telemedicine as an effective intervention to improve antibiotic appropriateness prescription and to reduce costs in pediatrics
Ceradini, J., Tozzi, A. E., D’Argenio, P., Bernaschi, P., Manuri, L., Brusco, C., & Raponi, M. (2017) · The Italian Journal of Pediatrics/Italian journal of pediatrics · doi:10.1186/s13052-017-0423-3 · Cited by 32
Rising Incidence of Clostridium difficile Related Discharges among Hospitalized Children in the United States
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Impact of computerized pre-authorization of broad spectrum antibiotics in Pseudomonas aeruginosa at a children's hospital in Japan
Horikoshi, Y., Higuchi, H., Suwa, J., Isogai, M., Shoji, T., & Ito, K. (2016) · Journal of Infection and Chemotherapy · doi:10.1016/j.jiac.2016.05.001 · Cited by 30
A Handshake From Antimicrobial Stewardship Opens Doors for Infectious Disease Consultations
Messacar, K., Campbell, K. R., Pearce, K., Pyle, L. L., Hurst, A. L., Child, J., & Parker, S. K. (2017) · Clinical Infectious Diseases · doi:10.1093/cid/cix139 · Cited by 30
Effect of Financially Punished Audit and Feedback in a Pediatric Setting in China, within an Antimicrobial Stewardship Program, and as Part of an International Accreditation Process
Gong, S., Qiu, X., Song, Y., Sun, X., He, Y., Chen, Y., Li, M., Luo, R., He, L., Wei, Q., et al. (2016) · Frontiers in Public Health · doi:10.3389/fpubh.2016.00099 · Cited by 29
Use of a Computerized C-Reactive Protein (CRP) Based Sepsis Evaluation in Very Low Birth Weight (VLBW) Infants: A Five-Year Experience
Coggins, S. A., Wynn, J. L., Hill, M. L., Slaughter, J. C., Weitkamp, A. O., Jalloh, O., Waitman, L. R., Carnevale, R. J., & Weitkamp, J.-H. (2013) · PLoS ONE · doi:10.1371/journal.pone.0078602 · Cited by 28
A point prevalence study of infection and antimicrobial use at a UK children's hospital
Ang, L. Y., Laskar, R., & Gray, J. W. (2008) · Journal of Hospital Infection · doi:10.1016/j.jhin.2008.01.030 · Cited by 27
A multifaceted approach to decrease inappropriate antibiotic use in a pediatric outpatient clinic
Al-Tawfiq, J., & Alawami, A. H. (2017) · Annals of Thoracic Medicine · doi:10.4103/1817-1737.197779 · Cited by 27
Perioperative antimicrobial prophylaxis in pediatric patients in Greece: Compliance with guidelines and impact of an educational intervention
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Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback
Willis, Z., Gillon, J., Xu, M., Slaughter, J. C., & Pentima, M. C. D. (2016) · Journal of the Pediatric Infectious Diseases Society · doi:10.1093/jpids/piw054 · Cited by 26
Impact of a training intervention on use of antimicrobials in teaching hospitals
Akter, S. F. U., Heller, R. F., Smith, A. J., & Milly, A. F. (2009) · The Journal of Infection in Developing Countries · doi:10.3855/jidc.416 · Cited by 25
Reducing Second Gram-Negative Antibiotic Therapy on Pediatric Oncology and Hematopoietic Stem Cell Transplantation Services
Wattier, R. L., Levy, E. R., Sabnis, A. J., Dvorak, C. C., & Auerbach, A. D. (2017) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2017.118 · Cited by 25
Clinical and Microbiologic Assessment of Cases of Pediatric Community-associated Clostridium difficile Infection Reveals Opportunities for Improved Testing Decisions
Kociolek, L., Patel, S. J., Zheng, X.-T., Todd, K., Shulman, S., & Gerding, D. (2015) · The Pediatric Infectious Disease Journal · doi:10.1097/inf.0000000000000954 · Cited by 24
Clinical Diagnoses and Antimicrobials Predictive of Pediatric Antimicrobial Stewardship Recommendations: A Program Evaluation
Goldman, J. L., Lee, B. R., Hersh, A. L., Yu, D., Stach, L. M., Myers, A., Jackson, M. A., Day, J. C., McCulloh, R. J., & Newland, J. G. (2015) · Infection Control and Hospital Epidemiology · doi:10.1017/ice.2015.45 · Cited by 24
Cost‐effectiveness analysis of a multi‐dimensional intervention to reduce inappropriate antibiotic prescribing for children with upper respiratory tract infections in China
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A Population-Based Observational Study of Restrictive Guidelines for Antibiotic Therapy in Early-Onset Neonatal Infections
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Clinical Impact of an Antimicrobial Stewardship Program on Pediatric Hospitalist Practice, a 5-Year Retrospective Analysis
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Interventions to improve antibiotic prescribing practices for hospital inpatients
Davey, P. G., Brown, E., & Hartman, G. (2002) · doi:10.1002/14651858.cd003543 · Cited by 22
Implications and Impact of Prior Authorization Policy on Vancomycin Use at a Tertiary Pediatric Teaching Hospital
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A Quality Assessment of a Collaborative Model of a Pediatric Antimicrobial Stewardship Program
Nguyen-Ha, P.-T., Howrie, D. L., Crowley, K. L., Vetterly, C. G., McGhee, W., Berry, D., Ferguson, E. H., Polischuk, E., Brooks, M. M., Goff, J., et al. (2016) · PEDIATRICS · doi:10.1542/peds.2015-0316 · Cited by 20
A Comprehensive Approach to Pediatric Pneumonia: Relationship Between Standardization, Antimicrobial Stewardship, Clinical Testing, and Cost
Rutman, L., Wright, D. R., O'Callaghan, J. P., Spencer, S. M., Lion, K. C., Kronman, M. P., Zhou, C., & Mangione-Smith, R. M. (2016) · Journal for Healthcare Quality · doi:10.1097/jhq.0000000000000048 · Cited by 20
Monitoring adherence to guidelines of antibiotic use in pediatric pneumonia: the MAREA study
the Pediatric Ligurian Network MAREA network, Pietro, P. D., Alberighi, O. D. C., Silvestri, M., Tosca, M. A., Ruocco, A., Conforti, G., Rossi, G. A., Castagnola, E., Merlano, M. C., et al. (2017) · The Italian Journal of Pediatrics/Italian journal of pediatrics · doi:10.1186/s13052-017-0432-2 · Cited by 19
Observational pre–post study showed that a quality improvement project reduced paediatric antibiotic prescribing rates in primary care
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Impact of Unlabeled French Antibiotic Guidelines On Antibiotic Prescriptions For Acute Respiratory Tract Infections In 7 Pediatric Emergency Departments, 2009–2012
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A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis
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Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line
Parker, S. K., Hurst, A. L., Thurm, C. W., Millard, M., Jenkins, T. C., Child, J., & Dugan, C. (2017) · Clinical Infectious Diseases · doi:10.1093/cid/cix631 · Cited by 18
Impact analysis of an evidence-based guideline on diagnosis of urinary tract infection in infants and young children with unexplained fever
Geurts, D. H. F., Vos, W., Moll, H. A., & Oostenbrink, R. (2013) · European Journal of Pediatrics · doi:10.1007/s00431-013-2182-5 · Cited by 17
A controlled intervention study to improve antibiotic use in a Russian paediatric hospital
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Acceptance of Pharmacist-Driven Antimicrobial Stewardship Recommendations With Differing Levels of Physician Involvement in a Children’s Hospital
Molloy, L. M., McGrath, E. J., Thomas, R., Kaye, K. S., & Rybak, M. J. (2016) · Clinical Pediatrics · doi:10.1177/0009922816678598 · Cited by 17
Comparison of Procalcitonin Guidance-Administered Antibiotics with Standard Guidelines on Antibiotic Therapy in Children with Lower Respiratory Tract Infections: A Retrospective Study in China
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Implementing an Inpatient Pediatric Prospective Audit and Feedback Antimicrobial Stewardship Program Within a Larger Medical Center
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Impact assessment of a decision rule for using antibiotics in pneumonia: A randomized trial
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Pilotprojekt einer pädiatrischen Antibiotic-Stewardship-Initiative am Dr. von Haunerschen Kinderspital - neue Wege der pädiatrischen Infektiologie
Hüebner, J., Rack-Hoch, A., Pecar, A., Schmid, I., Klein, C., & Borde, J. (2013) · Klinische Pädiatrie · doi:10.1055/s-0033-1349063 · Cited by 15
Quantitative evaluation of a clinical intervention aimed at changing prescriber behaviour in response to new guidelines
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Adoption of Electronic Medical Record‐Based Decision Support for Otitis Media in Children
Fiks, A. G., Zhang, P., Localio, A. R., Khan, S., Grundmeier, R. W., Karavite, D., Bailey, L. C., Alessandrini, E. A., & Forrest, C. B. (2014) · Health Services Research · doi:10.1111/1475-6773.12240 · Cited by 14
Antibiotic weight‐watching: slimming down on antibiotic use in a NICU
Liem, T. B. Y., van den Hoogen, A., Rademaker, C. M. A., Egberts, T. C. G., Fleer, A., & Krediet, T. G. (2010) · Acta Paediatrica · doi:10.1111/j.1651-2227.2010.01957.x · Cited by 13
Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support
Warhurst, H., Smith, S., Cox, E. G., Crumby, A. S., Nichols, K. R., & Webber, E. C. (2013) · Applied Clinical Informatics · doi:10.4338/aci-2013-07-ra-0054 · Cited by 13
A regionwide intervention to promote appropriate antibiotic use in children reversed trends in erythromycin resistance toStreptococcus pyogenes
Gagliotti, C., Buttazzi, R., Mario, S. D., Morsillo, F., & Moro, M. L. (2015) · Acta Paediatrica · doi:10.1111/apa.13072 · Cited by 12
Safety of Automatic End Dates for Antimicrobial Orders to Facilitate Stewardship
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Improvements in antibiotic prescribing by community paediatricians in the Czech Republic
Jindrák, V., Marek, J., Vaniš, V., Urbášková, P., Vlček, J., Janiga, L., & Marešová, V. (2008) · Eurosurveillance · doi:10.2807/ese.13.46.19040-en · Cited by 11
Vancomycin Use: Room for Improvement Among Hospitalized Children
Gillon, J., Xu, M., Slaughter, J. C., & Pentima, M. C. D. (2016) · Journal of Pharmacy Practice · doi:10.1177/0897190016635478 · Cited by 11
Evaluation of a Second-Sign Process for Antimicrobial Prior Authorization
Dassner, A. M., & Girotto, J. E. (2017) · Journal of the Pediatric Infectious Diseases Society · doi:10.1093/jpids/pix015 · Cited by 11
A Multisite Intervention for Pediatric Community‐acquired Pneumonia in Community Settings
McDaniel, C. E., Haaland, W. L., Parlaman, J., Zhou, C., & Desai, A. D. (2018) · Academic Emergency Medicine · doi:10.1111/acem.13405 · Cited by 11
Efectividad de un programa para mejorar el uso de antibióticos en niños internados en un hospital pediátrico de tercer nivel de atención en Argentina
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See all 199

Authors: Donà, D., Barbieri, E., Daverio, M., Lundin, R., Giaquinto, C., Zaoutis, T., & Sharland, M.
Affiliations: University of Padua (IT)
PENTA Foundation (IT)
Children's Hospital of Philadelphia (US)
St George's, University of London (GB)
Corresponding author: Barbieri, E.
ORCID: Donà, D.
Barbieri, E.
Daverio, M.
Lundin, R.
Giaquinto, C.
Sharland, M.
Venue: Antimicrobial Resistance & Infection Control
Publisher: Springer Science and Business Media LLC
Published: 2020-01-03
Volume: 9
Issue: 1
Pages: 3-3
ISSN: 2047-2994 (ISSN-L)
DOI: 10.1186/s13756-019-0659-3
PMC: PMC6942341
OpenAlex: W2998803677
Cited by: 199
References: 159
Citations by year: 2026: 29 · 2025: 39 · 2024: 32 · 2023: 31 · 2022: 21 · 2021: 32 · 2020: 15
FWCI: 3.60
Type: journal article
Language: en
Update notices: correction (2020-05-07)
Open access: gold
doi.org
Licence: cc-by
creativecommons.org/licenses/by/4.0/ (tdm)
creativecommons.org/licenses/by/4.0/ (vor)
Locations: Antimicrobial Resistance and Infection Control (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
St George's Online Research Archive (St George's University of London) (acceptedVersion)
DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Padua Research Archive (University of Padova) (submittedVersion)
Padua Research Archive (University of Padova) (submittedVersion, cc-by)
Topics: Health Sciences › Medicine › Infectious Diseases › Antibiotic Use and Resistance
Health Sciences › Medicine › Surgery › Surgical site infection prevention
Health Sciences › Medicine › Microbiology (medical) › Antibiotic Resistance in Bacteria
Keywords: antibiotic misuse, inappropriate antibiotic prescribing, antimicrobial resistance, health care costs, empirical antibiotic therapy, extended-spectrum beta-lactamase, carbapenem resistance, macrolide resistance, implementation outcomes
MeSH terms: Antimicrobial Stewardship, Anti-Bacterial Agents, Asia, Bacteria, Bacterial Infections, Child, Europe, Humans, Pediatrics, United States, Global Health, Drug Resistance, Bacterial, Inappropriate Prescribing, Prescription Drug Misuse

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Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

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