Effects of a comprehensive antibiotic stewardship program on antibiotic prescribing for acute respiratory infections in rural facilities: a cluster randomized trial.

Summary

In 34 rural township hospitals, a digitally enabled, multi-component stewardship program reduced antibiotic prescribing for ARIs from 71% to 26% across 97,239 consultations over 12 months (adjusted risk difference −39 percentage points; 95% CI, −47 to −29; P<0.001), with no increase in 30-day hospitalizations for respiratory illness or sepsis. The pragmatic cluster RCT supports scalable stewardship without compromising safety.

Key Findings

• Antibiotics were prescribed in 26% of intervention vs 71% of control consultations (adjusted risk difference −39 pp; 95% CI −47 to −29; P<0.001).
• No increase in 30-day hospitalization for respiratory illness or sepsis (adjusted risk difference 0.2 pp; 95% CI −0.3 to 0.6).
• A multi-component, digitally enabled program (EMR prompts, training, peer review, patient app) was feasible across 34 rural hospitals over 12 months.

Clinical Implications

Health systems can implement digitally supported stewardship (EMR prompts, peer feedback, training, patient education) to markedly reduce unnecessary antibiotics for ARIs without increasing short-term hospitalizations for respiratory illness or sepsis.

Limitations

• Conducted in two rural counties in Guangdong, China; generalizability to other settings may vary.
• Did not assess microbiologic outcomes or long-term resistance patterns.

Future Directions

Evaluate long-term resistance trends, cost-effectiveness, and scalability across diverse health systems; integrate microbiologic surveillance and patient-centered outcomes.