Identifying indicators for measuring appropriateness of antibiotic prescribing in high-income countries: a rapid systematic review

BACKGROUND: Antibiotics are essential for treating and preventing bacterial infections, yet inappropriate use drives the development of antimicrobial resistance, posing a major global health challenge. Antimicrobial stewardship aims to optimize antibiotic use, making the definition and measurement of 'appropriate' prescribing critical. OBJECTIVES: The primary objective was to identify indicators used to measure appropriateness of antibiotic prescribing in high-income countries (HICs). The secondary objective was to describe levels of inappropriate prescribing in HICs. METHODS: A rapid systematic review (PROSPERO registration no: CRD42024628584) was conducted using Embase, Medline, and Cochrane databases. Eligible peer-reviewed studies published from 2014 to January 2025 reported indicators for measuring appropriateness of antibiotic prescribing in HICs. Each article was independently reviewed for inclusion, extracted, and assessed for risk of bias by one reviewer, with 10% verified at each stage. RESULTS: This rapid review identified 103 unique indicators from 165 studies: 58 patient-specific/prescription-related (PSPR) indicators from 128 studies and 45 proxy indicators from 38 studies. The most frequent PSPR indicator was compliance with guidelines (95/128, 74.2%). This was followed by indicators related to appropriate duration (70/128, 54.7%) and appropriate dose (60/128, 46.9%). The most common proxy indicator was rate of prescribing by indication (22/38, 58%) followed by correct choice of antibiotic according to indication (14/38, 36.8%). Indicators were applied across diverse settings, populations, and types of infection. Among studies describing PSPR indicators, 103 of 128 gave quantifiable outcomes for inappropriateness of prescribing, which when standardized ranged from 2% to 88%. CONCLUSIONS: This review provides a comprehensive catalogue and categorization of both PSPR and proxy indicators of antibiotic prescribing appropriateness across HICs. Recurring themes reflect shared stewardship principles: prescribing the correct antibiotic, dose, frequency, and duration, in-line with guidance, and tailored to the clinical context. These findings provide a valuable resource for those monitoring antibiotic prescribing practices.