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Assessing the impact of antibiotic stewardship program elements on antibiotic use across acute-care hospitals: an observational study

  • Bradley J. Langford (a1) (a2), Julie Hui-Chih Wu (a1), Kevin A. Brown (a1) (a3), Xuesong Wang (a4), Valerie Leung (a1), Charlie Tan (a5), Gary Garber (a1) (a3) (a6) (a7) and Nick Daneman (a1) (a3) (a4) (a8) (a9)...

Antibiotic use varies widely between hospitals, but the influence of antimicrobial stewardship programs (ASPs) on this variability is not known. We aimed to determine the key structural and strategic aspects of ASPs associated with differences in risk-adjusted antibiotic utilization across facilities.


Observational study of acute-care hospitals in Ontario, Canada


A survey was sent to hospitals asking about both structural (8 elements) and strategic (32 elements) components of their ASP. Antibiotic use from hospital purchasing data was acquired for January 1 to December 31, 2014. Crude and adjusted defined daily doses per 1,000 patient days, accounting for hospital and aggregate patient characteristics, were calculated across facilities. Rate ratios (RR) of defined daily doses per 1,000 patient days were compared for hospitals with and without each antimicrobial stewardship element of interest.


Of 127 eligible hospitals, 73 (57%) participated in the study. There was a 7-fold range in antibiotic use across these facilities (min, 253 defined daily doses per 1,000 patient days; max, 1,872 defined daily doses per 1,000 patient days). The presence of designated funding or resources for the ASP (RRadjusted, 0·87; 95% CI, 0·75–0·99), prospective audit and feedback (RRadjusted, 0·80; 95% CI, 0·67–0·96), and intravenous-to-oral conversion policies (RRadjusted, 0·79; 95% CI, 0·64–0·99) were associated with lower risk-adjusted antibiotic use.


Wide variability in antibiotic use across hospitals may be partially explained by both structural and strategic ASP elements. The presence of funding and resources, prospective audit and feedback, and intravenous-to-oral conversion should be considered priority elements of a robust ASP.

Corresponding author
Author for correspondence: Bradley J. Langford, Public Health Ontario, 480 University Ave, Toronto, ON, Canada, M5G 1V2. E-mail:
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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