Mind the gap: Ontario hospitals face antimicrobial stewardship resource challenges

HN Summary

• Stewardship programs are widespread: 96 per cent of responding Ontario hospitals reported having an antimicrobial stewardship program or plans to implement one, but resources vary considerably across the province. 

• Staffing and funding remain major gaps: Only 63 per cent of programs had designated funding or resources, with smaller hospitals particularly affected. Staffing levels also fell below national recommendations.

• Data needs to drive action: While 75 per cent of hospitals tracked antimicrobial use, only 44 per cent routinely shared reports with prescribers, highlighting opportunities to strengthen stewardship and the fight against antimicrobial resistance.

Antimicrobial resistance is one of the most persistent threats facing modern health care. As bacteria and other microorganisms become resistant to the drugs designed to treat them, infections become more difficult to manage and the effectiveness of some of medicine’s most important treatments is put at risk.

Inside hospitals, antimicrobial stewardship programs are one of the key lines of defence.

These programs work to ensure antibiotics and other antimicrobial medications are used appropriately — selecting the right treatment, dose and duration while reducing unnecessary use that can contribute to resistance.

Canadian hospitals have been required to have antimicrobial stewardship programs since 2013. But a new Ontario study suggests that simply having a program in place doesn’t necessarily mean hospitals have the resources required to maximize its impact.

Researchers from Public Health Ontario and several Ontario academic and health-care institutions examined antimicrobial stewardship program resources and practices across the province, revealing significant differences in funding, staffing and implementation — particularly between larger and smaller hospitals.

The study, Mind the gap: a cross-sectional study of antimicrobial stewardship program resources and practice in Ontario hospitals, was published in September in the journal Antimicrobial Stewardship & Healthcare Epidemiology.

Researchers surveyed Ontario inpatient hospitals between January and March 2026. Of 128 eligible hospitals, 93 responded, representing a 73 per cent response rate.

The good news is that antimicrobial stewardship is now firmly established in most Ontario hospitals.

Ninety-six per cent of responding hospitals reported having a formal antimicrobial stewardship program or being in the process of implementing one within the next 12 months.

But beneath that high adoption rate, researchers found substantial differences in the resources available to support the work.

A funding divide

Overall, just 63 per cent of antimicrobial stewardship programs reported having designated funding or resources.

The divide was particularly noticeable when researchers looked at hospital size.

Among teaching hospitals, 89 per cent reported designated funding, as did 95 per cent of large hospitals. That fell to 63 per cent among medium-sized hospitals and just 21 per cent among small hospitals.

Staffing levels also fell below national recommendations.

For teaching, large and medium hospitals, researchers found an average of 0.19 pharmacist full-time equivalents and 0.04 physician full-time equivalents dedicated to antimicrobial stewardship for every 100 beds.

National recommendations call for at least 0.3 pharmacist and 0.1 physician full-time equivalents per 100 beds.

Smaller hospitals and complex continuing care and rehabilitation facilities were also below recommended minimum staffing levels.

Lack of resources — particularly funding and staffing — was identified as a challenge by 72 per cent of responding organizations.

The findings point to an important issue for hospitals: antimicrobial stewardship increasingly involves much more than establishing policies around antibiotic prescribing. Effective programs require clinical expertise, monitoring, data analysis, feedback and ongoing quality improvement.

Collecting data is only part of the equation

The study also uncovered a gap between hospitals collecting information about antimicrobial use and getting that information into the hands of prescribers.

Three-quarters of responding hospitals tracked hospital-wide antimicrobial use.

However, only 44 per cent routinely distributed antimicrobial-use reports to prescribers.

That distinction matters because tracking antibiotic use is most valuable when the information can help clinicians identify prescribing patterns, compare performance and determine where practice could be improved.

Only 36 per cent of antimicrobial stewardship programs reported that goals related to improving antimicrobial stewardship practices or antimicrobial use were formally included in their organization’s strategic or quality improvement plan.

Researchers identified metrics and benchmarking as an area where some organizations hope to improve.

Stewardship is evolving

Despite the resource challenges, the study also found evidence that antimicrobial stewardship practices are evolving.

Among the most commonly reported strategies were the use of antibiograms, which help clinicians understand local patterns of antimicrobial susceptibility; programs that support switching appropriate patients from intravenous to oral antibiotics; prospective audit and feedback; and hospital-specific prescribing guidelines.

Eighty-four per cent of respondents reported using antibiograms, while 67 per cent had IV-to-oral conversion initiatives. Sixty-five per cent reported prospective audit and feedback programs and 62 per cent used facility-specific guidelines.

Newer approaches are also gaining ground

Nearly half of hospitals reported antimicrobial stewardship involvement in allergy assessment, while half were using clinical decision-support tools.

These initiatives can help clinicians make more informed prescribing decisions and address issues that can lead to unnecessary use of broad-spectrum antibiotics.

However, researchers found considerable variation in how some strategies were delivered. Prospective audit and feedback — in which antimicrobial use is reviewed and recommendations are provided to prescribers — differed in its scope, frequency and target patient populations. Uptake was generally lower and implementation more variable among smaller hospitals.

Moving beyond compliance

The findings suggest Ontario has made significant progress in establishing antimicrobial stewardship across its hospitals. The next challenge may be ensuring those programs have the resources and organizational support required to move beyond meeting basic requirements.

The researchers concluded that Ontario hospital programs are advancing in areas including allergy assessment and clinical decision support, but persistent under-resourcing continues to limit their scope and potential impact, particularly in smaller organizations.

They suggest that stronger provincial data infrastructure and scaled or regional approaches to stewardship could help hospitals participate more effectively in the broader fight against antimicrobial resistance.

Additional investment will also be important if programs are expected to incorporate benchmarking, expand quality-improvement initiatives and keep pace with evolving stewardship standards.

The study has limitations. Participation was voluntary and the information was self-reported at the organizational level. The authors note that hospitals with more established and better-resourced programs may have been more likely to participate.

Still, with responses from nearly three-quarters of eligible hospitals, the findings provide a broad snapshot of antimicrobial stewardship in Ontario in 2026.

The picture that emerges is one of progress — but also unfinished work.

Most hospitals now have antimicrobial stewardship programs. Many are introducing increasingly sophisticated tools and strategies to improve prescribing. But the study suggests that the ability to put those strategies into practice remains heavily influenced by something much more fundamental: having enough people, funding and organizational support to do the work.

As antimicrobial resistance continues to challenge health systems, closing those gaps could determine how effectively hospital stewardship programs can help preserve the medications clinicians rely on to treat infection.

Source: This article is based on Mind the gap: a cross-sectional study of antimicrobial stewardship program resources and practice in Ontario hospitals by Valerie Leung, Sera Thomas, Kevin A. Brown, Nick Daneman, Kevin L. Schwartz and Bradley J. Langford, published online September 14, 2026 in Antimicrobial Stewardship & Healthcare Epidemiology, Volume 6, Issue 1, by Cambridge University Press on behalf of the Society for Healthcare Epidemiology of America.

Read the original study in Antimicrobial Stewardship & Healthcare Epidemiology

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