Measuring appropriateness of antibiotic prescribing in high-income countries: a rapid systematic review of indicators

BackgroundAntimicrobials are essential for treating and preventing bacterial infections, yet inappropriate use drives the development of antimicrobial resistance (AMR), posing a major global health challenge. Antimicrobial stewardship (AMS) aims to optimise antibiotic use, making the definition and measurement of "appropriate" prescribing critical. ObjectivesThe primary objective was to identify indicators used to measure appropriateness of antibiotic prescribing in high-income countries. The secondary objective was to describe levels of inappropriate prescribing in high-income countries. MethodsA rapid systematic review (registration no: CRD42024628584) was conducted using Embase, Medline and Cochrane databases. Eligible studies reported indicators for measuring appropriateness of antibiotic prescribing in high-income countries. Each article was independently reviewed for inclusion, extracted, and assessed for risk of bias by one reviewer, with dual screening of 10%. Indicators were grouped as general or proxy indicators, further synthesised thematically, and described narratively. Quantitative data on inappropriateness for general indicators were standardised and summarised. ResultsThis rapid review identified 103 unique indicators from 165 studies: 58 general indicators from 128 studies and 45 proxy indicators from 38 studies. The most frequent general indicator was compliance with guidelines (90/128, 70%). The most common proxy indicator was rate of prescribing by indication (22/38, 58%). Indicators were applied across diverse settings, populations, and types of infection. Among studies describing general indicators, 103/128 gave quantifiable outcomes for inappropriateness of prescribing, ranging from 2% to 88%. ConclusionsThe review highlights the wide variety of indicators used to assess appropriateness of antibiotic use in high-income countries, reflecting the complexity of the concept. Most indicators focused on whether the correct antibiotic, dose, frequency, and duration was prescribed, in-line with clinical guidance and tailored to the clinical context - core principles of AMS. These findings provide a valuable resource for those aiming to monitor and improve antibiotic prescribing practices.