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preauthorization, prospective audit and feedback, therapeutic drug monitoring with feedback, and intravenous-to-oral conversion.3


Methods Study design and setting


We conducted an observational study of acute-care hospitals in Ontario, Canada, to evaluate the association between self-reported ASP characteristics in place as of 2013 and risk-adjusted antibiotic utilization for the 2014 calendar year.


Antimicrobial stewardship program survey


The Ontario ASP Landscape survey, developed by Public Health Ontario, asked clinicians about the structural and strategic


Table 1. Structural and Strategic Antimicrobial Stewardship Program (ASP) Elements


Structural Elements of ASP (n=8) ∙ Presence vs. absence of formal ASP ∙ Maturity of ASP (in place for at least 3 years) ∙ Designated funding/resources for ASP ∙ Presence of a physician champion ∙ Presence of a pharmacist champion ∙ Presence of an antimicrobial stewardship committee (ASC) ∙ Metrics reported to senior administration ∙ Recognition as an organizational priority (antimicrobial use is part of the organization’s quality improvement plan and/or a strategic goal/ priority)


Strategic Elements of ASP (n=32) Formulary-related Strategies ∙ Formulary automatic substitution/therapeutic interchange policies ∙ Formulary restriction ∙ Formulary restriction with preauthorization ∙ Formulary review/streamlining


Process Strategies ∙ Automatic stop orders ∙ Checklists ∙ Drug use evaluation/medication use evaluation ∙ General antimicrobial order forms ∙ Improved antimicrobial documentation ∙ Surgical antibiotic prophylaxis optimization ∙ Systematic antibiotic allergy verification


Clinical Strategies ∙ De-escalation and streamlining ∙ Dose optimization ∙ Identification of inappropriate pathogen/antimicrobial combinations ∙ Preventing treatment of noninfectious conditions ∙ Prospective audit and feedback ∙ Scheduled antimicrobial reassessments ∙ Targeted review of patients with Clostridium difficile infection ∙ Targeted review of patients with bacteremia/fungemia ∙ Targeted review of redundant therapy or therapeutic duplication ∙ Therapeutic drug monitoring (with feedback) Prescribing Guidance Strategies ∙ Clinical decision support systems/computerized physician order entry ∙ Disease-specific treatment guidelines/pathways/algorithms and/or order forms


∙ Empiric antibiotic prescribing guidelines ∙ Facilitation of appropriate and timely antimicrobial administration in severe sepsis/septic shock


∙ intravenous-to-oral conversion ∙ Prescriber education Microbiology-Related Strategies ∙ Antibiograms ∙ Cascading microbiology susceptibility reporting ∙ Improved diagnostics ∙ Promotion of timely and appropriate microbiologic sampling ∙ Strategic microbiology results reporting


Bradley Langford et al


elements of their organization’s ASP (Table 1). The survey was pilot tested by selected individuals involved in hospital ASPs (eg, pharmacists, program leads) and was refined based on their feedback prior to dissemination. The voluntary survey, adminis- tered online and open for 5 weeks (September–October, 2016), was distributed to all hospitals and was addressed to the individual most responsible for antimicrobial stewardship in their organization (eg, ASP pharmacist or physician). Respondents were asked the year of ASP element implementation. Only elements implemented in 2013 or prior were considered present for the purposes of this analysis. The ASP elements implemented in 2014 and later or with year unknown were considered absent (due to respondent uncer- tainty of whether these elements were present prior to 2014).


Antibiotic use


Monthly antibiotic purchasing from January 1 to December 31, 2014, for acute-care hospitals in Ontario was included in this dataset in grams for each antibiotic and was converted to defined daily doses, a standard metric defined by the World Health Organization for benchmarking drug utilization.7 All systemic antibacterials administered by the enteral or parenteral route were included. Purchasing data were obtained from the IMS Health Canadian Drug Store and Hospital Purchases Audit, which includes direct and indirect drug sales to hospitals and pharma- cies across Canada. These data have been validated, showing a strong correlation with internal hospital records of antibiotic dispensing (correlation coefficient, 0.88–0.91).8


Data on acute-care hospitals and hospitalizations


Eligible hospitals included acute-care facilities in Ontario. Hospitals that specialized only in psychiatric, surgical, pediatric, outpatient, rehabilitation or long-term geriatric care were exclu- ded given the anticipated low rates of antibiotic use and the paucity of antibiotic stewardship efforts. Two hospitals that purchased antibiotics for nursing station outposts in their area were excluded because their inpatient antibiotic use would be overestimated. Hospitals with shared purchasing or pooled administrative data were combined (eg, multiple hospital sites within a hospital corporation). Hospital-level variables collected for this study were based on a previous work of risk-adjusted variability in hospital antibiotic use in Ontario.5 The number of patient days from inpatient admissions and same-day surgeries in 2014 at each hospital were obtained from Canadian Institutes of Health Information Discharge Abstracts Database and Same-Day Surgery databases, respectively. Hospital characteristics collected are shown in Table 2.


Privacy and ethics


The Privacy Office and Ethics Review Board at Public Health Ontario approved this study.


Primary outcome Antibiotic use was expressed in defined daily doses per 1,000 patient days at each hospital.


Statistical analysis


A multivariable generalized estimating equations (GEE) Poisson regression model, using defined daily doses as the outcome and the log of hospital patient days as the offset, was developed. The


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