Antimicrobial stewardship interventions in the WHO Eastern Mediterranean Region Countries: a scoping review of clinical, economic, and consumption outcomes.

BACKGROUND: Antimicrobial stewardship program (ASP) interventions are designed to optimize antimicrobial use, reduce adverse effects, and address antimicrobial resistance (AMR). In WHO Eastern Mediterranean Office (EMRO) countries, these efforts are important due to high antibiotic use, evolving resistance patterns, and developing regulatory frameworks. OBJECTIVES: This scoping review evaluates ASP interventions in EMRO countries by systematically mapping their strategies, clinical, economic, and consumption outcomes, as well as identifying their barriers/limitations to effective implementation. METHODS: This scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A systematic literature search was performed without a time limitation to the end of December 2024 across four major databases-PubMed, Embase, Web of Science, and Scopus-to identify relevant peer-reviewed studies. The search was limited to English-language publications originating from EMRO countries. Eligible studies were required to evaluate ASP interventions and report comparative pre- and post-intervention outcomes. Eligible studies involved healthcare workers or patients. A qualitative color intensity classification system was applied within a thematic matrix to visually represent the relative impact of antimicrobial stewardship interventions. Intensity levels (Dark, Medium, Light) reflected the clinical and managerial relevance of outcomes across economic, clinical, and adherence-related domains. RESULTS: A total of 77 studies with 199 interventions from 11 EMRO countries were included, with the majority originating from Saudi Arabia (n = 50, 25.12%), the United Arab Emirates (n = 33, 16.58%), and Iran (n = 28, 14.07%). Audit and feedback were the most frequent interventions (n = 50, 25.12%), followed by restrictive, educational, and protocol-driven strategies (each n = 26, 13.06%). Most interventions targeted adults (n = 52, 26.13%) and were implemented in hospital settings (n = 160, 82.05%), primarily at the tertiary level of care. High-impact outcomes-mainly for audit and feedback-included reduced antibiotic use, AMR, and costs. Common limitations were single-center design (n = 40, 18.26%) and poor documentation (n = 33, 15.06%). CONCLUSIONS: ASP interventions in the EMRO region show varying effectiveness, with audit and feedback proving most successful. Regional cooperation and continued efforts are essential to overcome challenges and strengthen these programs. Future efforts should focus on standardized implementation, improved reporting, and further research to effectively scale successful ASP strategies across the EMRO region. To the authors' best knowledge, this is the first scoping review of ASP interventions in EMRO countries summarizing their strategies, outcomes, and challenges.