A survey of US hospitals in 2023 shows the overall rate of antibiotic use hasn’t budged since 2015, despite an increase in antibiotic stewardship programs (ASPs).

The point-prevalence survey, conducted from May 1 to September 30 at hospitals in 10 states by researchers with the Centers for Disease Control and Prevention (CDC) and state public health departments, found that ASPs were present in 215 (98.6%) of 218 hospitals, compared with 158 (79.4%) of 199 hospitals in a similar survey conducted in 2015. 

That increase reflects efforts by the CDC and other federal agencies to prioritize judicious use of antibiotics in hospitals. In 2014, the CDC published the Core Elements of Hospital Antibiotic Stewardship Programs, a roadmap to help hospitals develop and implement ASPs. In 2019, the Centers for Medicare and Medicaid Services (CMS) adopted a rule that requires all acute-care hospitals that take part in CMS programs to implement ASPs.

The survey was intended, in part, to assess changes in antibiotic stewardship practices at US hospitals since 2015. But its main purpose was to determine the impact of stewardship on antibiotic prescribing.

“Although these developments signal substantial progress, measuring their impact on AU [antibiotic use] within hospitals remains essential,” the study authors wrote last week in Open Forum Infectious Diseases.

An analysis of medical records from 13,653 randomly selected patients at the 218 hospitals found that 49.7% received one or more antibiotics on or the day before the survey date, mostly broad-spectrum antibiotics. But among the 151 hospitals that participated in both surveys, the overall AU prevalence was similar: 49.2% in 2015 versus 49.1% in 2023.

While overall AU remained stable, there were notable declines in use in neonatal critical care units (from 23.4% to 17.1%) and increases in mother-baby units (24.4% to 32.8%). The authors say the observed decline in neonatal AU is part of a trend that’s been documented over the past decade.

“Stewardship interventions such as sepsis risk calculators, diagnostic stewardship, and policies targeting early-life antibiotic exposure have been associated with reductions in neonatal AU without increases in adverse outcomes,” they wrote.

There was also a significant decline in fluoroquinolone use (9.2% to 2.8%), likely connected to stewardship efforts and Food and Drug Administration warnings about adverse events associated with fluoroquinolones. At the same time, use of third- or fourth-generation cephalosporins rose from 12.3% to 18.6%.

Given the increasing complexity of inpatient care, substantial reductions in overall hospital AU prevalence may be difficult to achieve, and lower AU prevalence alone may not reflect optimized use.

The most common infections treated in both surveys were pneumonia, urinary tract infections, and skin and soft-tissue infections. In the 2023 survey, higher AU was independently associated with being in a critical care or medical-surgical unit; the presence of a central line, urinary catheter, or ventilator; obesity or severe obesity; hospital stays of four to 17 days; and suburban residence.

The authors say the results should not be interpreted as evidence that antibiotic stewardship efforts were ineffective.

“Given the increasing complexity of inpatient care, substantial reductions in overall hospital AU prevalence may be difficult to achieve, and lower AU prevalence alone may not reflect optimized use,” they wrote, adding that targeted efforts focused on specific patient groups and inpatient settings “may be most impactful.”