Discussion

This cross-sectional study of 93 organizations with a survey response rate of 73% describes the current state of hospital antimicrobial stewardship programs in 2026, more than a decade after becoming an accreditation requirement and in the context of evolving national and international guidance. A significant proportion of programs continue to lack designated resources; 50% of ASPs had no dedicated funding in 2016, compared to 37% in 2026. ^{Reference Leung, Wu, Langford and Garber6} When comparing ASP strategy implementation in 2016–2026, the extent appears to be similar for most interventions: antibiograms (81% vs 84%), IV-to-PO conversion (71% vs 67%), PAF (65% vs 65%), prescribing guidelines (63% vs 62%), and formulary restriction with preauthorization (29% vs 20%). ^{Reference Leung, Wu, Langford and Garber6}

That said, there was a large increase for systematic allergy assessment (6% vs 46%) and clinical decision support (12% vs 50%) reflecting advances in evidence and technology. ^{Reference Leung, Wu, Langford and Garber6} Aligning with newer literature recognizing penicillin allergy labels as a modifiable driver of inappropriate antibiotic use, almost half of ASPs reported implementing interventions targeting this. The development of validated risk stratification tools such as PEN-FAST and evidence supporting direct oral challenge in low-risk patients has facilitated integration of penicillin allergy assessment and de-labeling into ASP workflows. ^{Reference Trubiano, Vogrin and Chua18} Additionally, a better understanding of β-lactam cross-reactivity has improved the use of first-line agents in patients with penicillin allergy, with many ASPs reporting implementation of policies and clinical decision support to optimize the use of cefazolin for peri-operative prophylaxis. ^{Reference Jeimy, Ben-Shoshan, Abrams, Ellis, Connors and Wong19}

About two-thirds of organizations reported conducting PAF; however, a wide variety of models were reported. In this study, there were differences in the scope of PAF being performed. Medium and large hospitals tend to perform hospital-wide PAF, while teaching and smaller hospitals frequently conduct PAF for targeted services/units typically covering ICU, general medicine, and general surgery. For smaller hospitals, this most likely reflects lack of resources but for teaching hospitals the presence of specialty services requiring tailored approaches may also limit the scope of PAF. Conversely, some ASPs may leverage clinical pharmacists to support PAF activities on their units. Frequency of review was also quite variable; it was most common to perform PAF daily or several times per week, but a small number reported PAF being performed less frequently. While generally regarded as a high-impact intervention, previous literature has shown that the intensity of PAF interventions can influence outcomes; the variation in this study raises the opportunity to explore the role of more clear terminology when describing PAF, further evaluation of different PAF models, and potentially a more standardized approach to PAF in the future. ^{Reference Langford, Brown, Chan and Downing20,Reference Chung, Wu, Yeo, Chan and Hsu21}

As an increasing number of organizations adopt Computerized Provider Order Entry (CPOE), CDS functions are also being deployed to amplify other stewardship strategies and to address historical gaps in documentation. In this survey, many organizations are using CDS to implement mandatory indication and duration documentation and/or eligibility criteria to support formulary restriction at the time of prescribing which were historically more difficult interventions to deploy using a paper system. However, transitions to new clinical information systems were also frequently cited as barriers to accessing antimicrobial use metrics and a strain on already limited resources, suggesting that newer clinical information systems may not necessarily reduce workload in the short term.

Inadequate ASP resourcing remains the dominant challenge across Ontario hospitals and continues to constrain program scope and limit the potential impact. Firstly, many ASPs, mainly those in medium, small, and CCC/rehab hospitals, still report having no dedicated resources or funding for their ASPs. This is in contrast with a recent national survey of Canadian hospitals belonging to a sentinel surveillance network which found that 93% had dedicated pharmacist resources. ^{Reference McGill, Neitzel and Bartoszko22} Across all hospital types, the average FTE for pharmacist, physician, and total ASP staff in Ontario continues to be less than AMMI Canada recommendations, international recommendations and, in some cases, lower than historical averages (See Figure 1). ^{Reference Leung, Thomas, Brown, Daneman, Schwartz and Langford8,Reference Greene, Nesbitt and Nelson9} Even for larger institutions which tend to be better resourced, pharmacist FTE per 100 beds is 0.19 (vs 0.17–0.26 in 2021 and 2023) and physician FTE per 100 beds is 0.04 (vs 0.05 per 100 beds in 2021 and 2023). ^{Reference Leung, Thomas, Brown, Daneman, Schwartz and Langford8} This may reflect that while 56% of organizations included appropriate antibiotic use in strategic or quality plans in 2016, only one-third reported doing so in 2026, potentially signaling ASPs being viewed as less of an organizational priority. ^{Reference Leung, Wu, Langford and Garber6}

While hospital ASPs in Ontario continue to operate with limited resources, expectations for programs have evolved over time shifting away from foundational interventions towards high-impact but more resource-intensive interventions. ⁴ This, combined with new accreditation criteria that emphasize benchmarking and quality improvement, presents significant challenges. In 2026, although most organizations indicate that they are tracking hospital-wide AMU, fewer than half are routinely disseminating antimicrobial use reports to prescribers and only about half submit these data for provincial benchmarking purposes. ²³ Optimization of provincial data infrastructure and scaled or regionalized stewardship models may help hospital ASPs play a greater role within an overarching AMR mitigation strategy; however, without additional investment in hospital ASPs, it will be difficult for programs to advance beyond compliance with accreditation criteria to have significant program impact. ^{Reference Langford, Kang and Ji10}

A strength of this survey is its high response rate of 73%, which exceeds the generally accepted benchmark of 60%–70%. ^{Reference Burns, Duffett and Kho14} However, as with previous surveys, this was a voluntary questionnaire relying on self-reported, organization-level data. Consequently, the findings may be biased toward more established programs with dedicated funding and resources, as these are more likely to have the capacity to participate. Comparison with survey results may also be imprecise as participation by specific organizations can vary from year to year; however, with a consistent response rate of over 70%, this is minimized. ^{Reference Leung, Wu, Langford and Garber6,Reference Leung, Quirk, Muir, Daneman, Schwartz and Langford24}

In conclusion, while antimicrobial stewardship programs in Ontario hospitals have advanced in areas such as allergy assessment and clinical decision support, persistent gaps in funding continue to limit their scope and potential impact, particularly for smaller organizations. It will be challenging for most hospital ASPs to incorporate benchmarking and adopt a quality improvement approach without more dedicated resources and organizational prioritization.