Antimicrobial Resistance and Stewardship Programs in Saudi Arabia: A Decade of Implementation and Outcomes

Background Saudi Arabia faces substantial antimicrobial resistance burdens with rapidly escalating antibiotic consumption. Following the 2014 national antimicrobial stewardship plan and 2018 prescription restriction policy, comprehensive evaluation of decade-long implementation remains absent. This systematic review synthesizes evidence on antimicrobial resistance patterns, stewardship program effectiveness, clinical outcomes, economic impact, and educational initiatives across Saudi Arabian healthcare settings from 2014–2025. Methods We systematically searched PubMed, MEDLINE, Embase, and Cochrane Library from July 2014 to June 2025, supplemented by grey literature and government reports. Studies examining antimicrobial resistance surveillance, stewardship program implementation, clinical effectiveness, economic outcomes, or educational interventions in Saudi Arabian healthcare settings were included. Two independent reviewers screened studies and extracted data following PRISMA guidelines. Quality assessment utilized Newcastle-Ottawa Scale and Cochrane Risk of Bias tools. Evidence certainty was graded using GRADE methodology. Results Systematic searches identified 1, 847 records, with 42 studies meeting inclusion criteria. MRSA prevalence ranged from 8. 6% to 47%, with a pooled estimate of 24. 3% (95% CI: 19. 7–29. 4%) derived predominantly from cross-sectional and retrospective surveillance studies, with heterogeneity driven largely by differences in hospital type and specimen source. Following the 2018 prescription restriction policy, total antibiotic consumption decreased by 30%, though parenteral use paradoxically increased by 34%; these signals cannot establish causality and may reflect case mix shifts, coding changes, or supply channel changes rather than true clinical need. Stewardship programs demonstrated 15–40% reductions in inappropriate prescribing, 8–25% decreases in antimicrobial costs, and 12–35% reductions in hospital-acquired infections. Educational interventions improved healthcare provider knowledge scores by 25–45% and prescription appropriateness by 18–30%. Economic analyses revealed cost savings of 850–3, 200 per patient. Conclusions Saudi Arabia's decade-long antimicrobial stewardship initiatives demonstrate meaningful progress. However, rising ESBL and carbapenem resistance, implementation heterogeneity, and workforce constraints remain critical challenges requiring sustained investment.