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Nudging in MicroBiology Laboratory Evaluation (NiMBLE): A systematic review and meta-analysis
Journal article   Open access   Peer reviewed

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

Bradley J Langford, Elizabeth Leung, Esther Jeong, Kevin A Brown, Glyneva Bradley-Ridout, Vaishnav Sivakumar, Linda R Taggart, Jenna Wong, Aaron Scherer and Larissa M Matukas
Clinical microbiology and infection
04/17/2026
DOI: 10.1016/j.cmi.2026.04.008
PMID: 42001937
url
https://doi.org/10.1016/j.cmi.2026.04.008View
Published (Version of record) Open Access

Abstract

Antimicrobial 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. We conducted a systematic review and meta-analysis to evaluate the impact of nudging in microbiology reports on antimicrobial use and clinical outcomes. Data Sources: Following our PROSPERO-registered protocol (CRD42024568670), a search was conducted across four databases. All studies that evaluated clinical microbiology report nudges and prescribing and/or clinical outcomes were eligible. Studies in humans conducted in all healthcare settings were included. Selective, framing and eye-level nudging strategies in microbiology reports. Risk of bias was assessed using standard tools for each study design. Primary 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. We 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). Nudging 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.
 antimicrobial utilisation antimicrobial stewardship prescribing appropriateness clinical microbiology reporting behavioural nudging

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