Nudging In MicroBiology Laboratory Evaluation (NIMBLE): A scoping review

Background: Nudging in microbiology is an antimicrobial stewardship strategy to influence decision making through the strategic reporting of microbiology results while preserving prescriber autonomy. The purpose of this scoping review was to identify the evidence that demonstrates the effectiveness of nudging strategies in susceptibility result reporting to improve antimicrobial use. Methods: A search for studies in Ovid MEDLINE, Embase, PsycINFO, and All EBM Reviews was conducted. All simulated and vignette studies were excluded. Two independent reviewers were used throughout screening and data extraction. Results: Of a total of 1,346 citations screened, 15 relevant studies were identified. Study types included pre- and postintervention (n = 10), retrospective cohort (n = 4), and a randomized controlled trial (n = 1). Most studies were performed in acute-care settings (n = 13), and the remainder were in primary care (n = 2). Most studies used a strategy to alter the default antibiotic choices on the antibiotic report. All studies reported at least 1 outcome of antimicrobial use: utilization (n = 9), appropriateness (n = 7), de-escalation (n = 2), and cost (n = 1). Moreover, 12 studies reported an overall benefit in antimicrobial use outcomes associated with nudging, and 4 studies evaluated the association of nudging strategy with subsequent antimicrobial resistance, with 2 studies noting overall improvement. Conclusions: The number of heterogeneous studies evaluating the impact of applying nudging strategies to susceptibility result reports is small; however, most strategies do show promise in altering prescriber's antibiotic selection. Selective and cascade reporting of targeted agents in a hospital setting represent the majority of current research. Gaps and opportunities for future research identified from our scoping review include performing prospective randomized controlled trials and evaluating other approaches aside from selective reporting.