Abstract Introduction Prolonged intravenous (IV) antibiotic therapy, compared to oral (PO) therapy in hospitalised patients with pneumonia increases healthcare cost and hospital length of stay. 1 Antimicrobial stewardship (AMS) interventions promoting timely intravenous-to-oral (IV-to-PO) antibiotic conversion, may reduce healthcare burden without compromising patient outcomes. 2 However, the optimal design, implementation, and long-lasting effect of such interventions remain unclear across different healthcare settings in respiratory medicine. Aim To evaluate the effectiveness of interventions designed to improve IV-to-PO antibiotic switching in the management of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). Methods This review was registered with PROSPERO (CRD420251039180). Electronic databases (PubMed, Scopus, Web of Science, The Cochrane Library) were searched for studies published from 1995 to 2024. Keywords such as “community-acquired pneumonia and ‘antimicrobial stewardship’ were used. Eligible studies focused on CAP and/or HAP management or antimicrobials indicated for respiratory infections. Two reviewers independently screened study titles/abstracts and then full-text articles using a priori inclusion/exclusion criteria. Any discrepancies were resolved through discussion with a third reviewer. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Study characteristics including country of origin, patient demographics, intervention type, and reported outcomes (IV antibiotic duration, hospital length of stay and costs) were extracted. Effectiveness was assessed through clinical outcomes (cure rates, mortality and length of stay), economic outcomes (cost savings), and process measures (switching rates and IV antibiotic duration). Due to study heterogeneity, a narrative synthesis was performed. Results A total of 400 results were returned from the initial search. Fifty eight studies from 27 countries were included, most from the United States (n = 17). Quality assessment showed moderate-to-high methodological quality, with no studies excluded. Reported interventions were categorised as pharmacist-led interventions (pharmacists reviewed antimicrobial prescriptions and made recommendations to prescribers, or had autonomous prescribing authority), clinical guideline/protocol implementation, educational programmes, computerised decision support systems, multidisciplinary team approaches, and audit/feedback systems. Most studies reported AMS interventions promoted timely IV-to-PO switches in CAP/HAP management (1–3 day reductions in IV antibiotic duration), hospital length of stay reductions of 1. 38–4. 0 days and cost savings of 46–921 per patient. Clinical outcomes remained equivalent across all intervention types, with cure rates of 83–100% and 30-day readmission rates of 6–27% showing no significant differences compared to standard care. ‘Pharmacist-led interventions’ demonstrated high efficacy with physician acceptance rates exceeding 80%. Computerised decision support systems combined with pharmacist review achieved switch rate improvements from 34. 7% to 62. 7% (p 0. 05). Clinical guidelines and structured pathways reduced median IV therapy duration by 1–2 days, and hospital length of stay by up to 2. 1 days but were limited by clinicians’ unawareness of existing guidelines. Multimodal approaches, such as those combining pharmacist involvement with computerised alerts and education, consistently outperformed single interventions, achieving switch rate improvements of 35–67% and reducing hospital stays by 2–3 days compared to single-component interventions. Conclusion This review provides evidence that AMS interventions are effective in CAP and HAP management. We propose healthcare systems prioritise clinical pharmacist involvement in switching decisions, particularly when integrated with computerised decision support systems. Our key limitation is heterogeneity amongst the studies analysed, preventing meta-analysis.
Obed-Arthur et al. (Wed,) studied this question.