Discussion

ASPs were absent in half of the hospitals surveyed, and those with an ASP in place often lacked full implementation of the CDC core elements. Among DR hospitals with ASPs, 85.7% demonstrated leadership commitment and 100% accountability, differing from studies in the United States and other Latin American regions. Financial support for ASP was not specified. Over 95% of hospitals have established ASPs in the United States.^{Reference Neuhauser, McLees, Paek, Tappe and Srinivasan7} In Latin America, a 2015 survey of 27 hospitals across 10 countries found that 59.0% had a formal written statement supporting ASPs.^{Reference Muñoz, Motoa and Escandón-Vargas8} A 2022 study by Fabre et al., surveying 20 hospitals across 5 Latin American countries, found that 67% of ASPs had leadership support through a written document and a designated individual responsible for the program, while a 2023 review of ASPs in 7 Latin American countries identified hospital leadership support (57%) and monitoring/communication (54.4%) as the least developed core elements.^{6,Reference Neuhauser, McLees, Paek, Tappe and Srinivasan7}

Common interventions in DR hospitals with ASPs included documentation of indication and hospital-specific treatment guidelines, both implemented by 71% of hospitals. Less frequently adopted interventions included antimicrobial restriction and preauthorization (57%), PAF (57%), review of outpatient parenteral antibiotic therapy (29%), antibiotic time-out (14%), and assessment of beta-lactam allergies (14%). Comparatively, the 2015 Munoz et al. survey reported that only 37% of hospitals performed antibiotic time-out audits after 48 hours, although 74.1% required preauthorization of specific antimicrobials.^{Reference Muñoz, Motoa and Escandón-Vargas8} Tracking of antibiotic prescribing and monitoring was present in 85.7% of hospitals, and 71.0% fulfilled the Education core component by providing training on optimal antibiotic prescribing, side effects, and AMR within the last year. In contrast, the Fabre et al. study reported that only 35% of hospitals provided healthcare workers with education on ASP principles upon hiring.^{Reference Fabre, Secaira and Cosgrove9,Reference Pallares, Porras and De La Cadena10} Pharmacy expertise, such as the presence of a co-leader for the ASP, was reported in 57% of hospitals, while reporting of antibiotic usage data to prescribers was performed in only 42% of hospitals. Major barriers for effective ASP remain. Pharmacists are unable to formally specialize in the DR. Widespread over-the-counter access to antimicrobials in the DR, including at pharmacies and bodegas, contributes significantly to antimicrobial misuse and may limit the impact of hospital-based ASP.^{Reference Mena Lora, Rojas-Fermin, Bisono, Almonte and Bleasdale4}