What question did this study set out to answer?

This research aimed to evaluate how nudges in microbiology reports affect antimicrobial use and patient outcomes.

April 20, 2026Open Access

Nudging in MicroBiology Laboratory Evaluation (NiMBLE): A systematic review and meta-analysis

BLBradley J. LangfordHamilton Health Sciences ELElizabeth LeungSt. Michael's Hospital EJEsther JeongToronto Public Health

Key Points

This research aimed to evaluate how nudges in microbiology reports affect antimicrobial use and patient outcomes.
Conducted a systematic review and meta-analysis of studies on nudging in clinical microbiology reports.
Included studies that assessed nudging interventions in various healthcare settings.
Pooled outcomes related to prescribing appropriateness and antimicrobial usage using random-effects models.
Nudging interventions led to a 143% increase in prescribing appropriateness among studies.
Antimicrobial utilization was reduced by approximately 1.70 days of therapy.
No increase in negative outcomes such as longer hospital stays, mortality, or C. difficile infection rates was observed.

Abstract

BackgroundAntimicrobial stewardship programs (ASP) include collaborating with clinical microbiology laboratories to improve antimicrobial use.Several ASP guidelines recommend selective or cascade reporting of antimicrobial susceptibility results -a behavioural nudge which entails modifying choice architecture to guide prescribing without removing clinician autonomy. ObjectivesWe conducted a systematic review and meta-analysis to evaluate the impact of nudging in microbiology reports on antimicrobial use and clinical outcomes. Methods Data SourcesFollowing our PROSPERO-registered protocol (CRD42024568670), a search was conducted across four databases. Study eligibility criteriaAll studies that evaluated clinical microbiology report nudges and prescribing and/or clinical outcomes were eligible. ParticipantsStudies in humans conducted in all healthcare settings were included. InterventionsSelective, framing and eye-level nudging strategies in microbiology reports. Assessment of Risk of Bias J o u r n a l P r e -p r o o fRisk of bias was assessed using standard tools for each study design. Methods of Data SynthesisPrimary outcomes included prescribing appropriateness and antimicrobial utilisation.Secondary clinical outcomes included C. difficile infection rates, length of stay and mortality.Reported outcomes were pooled using random-effects meta-analysis. ResultsWe analysed 45 studies of the 36,339 records identified.Most studies were conducted among adult inpatient populations, in high-income countries, predominantly in North America.For prescribing appropriateness, nudging interventions were associated with a 143% increase (n=23 studies, OR = 2.43 1.91 to 3.10).Nudging reduced utilisation by 1.70 (n=7 studies, 95% CI 0.17 to 3.22) days of therapy.There was no evidence of increased harm; length of stay was 1.1 days longer without nudge (95% CI: -0.4 to 2.5); and no impact to mortality (OR 1.07, 95%CI: 0.65 to 1.76) or C. difficile infection rates (OR 1.08, 95%CI: 0.89 to 1.30). ConclusionsNudging improved antimicrobial appropriateness and utilisation, supporting its addition to ASPs.Future research should employ prospective designs to mitigate potential biases, and evaluate clinical outcomes, sustainability and generalisability.

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