Half of patients in American hospitals were receiving an antibiotic on a given day in 2023, essentially the same share as in 2015, even though formal stewardship programs went from covering roughly four in five hospitals to nearly all of them over that period.
The finding comes from a point-prevalence survey conducted by researchers at the Centers for Disease Control and Prevention and state health departments, published in Open Forum Infectious Diseases and reported by CIDRAP. Reviewers examined records for 13,653 randomly selected patients at 218 hospitals across 10 states, surveyed between May and September of that year.
It is a result worth sitting with rather than reacting to. Antibiotic stewardship is a genuinely well-supported practice, and a flat total does not establish that it failed.
The Survey and the Number That Did Not Move
Among all patients surveyed, 49.7 percent had received one or more antibiotics on or the day before the survey date, mostly broad-spectrum agents.
The more informative comparison comes from the 151 hospitals that participated in both the 2015 and 2023 surveys. In those facilities, the prevalence of antibiotic use was 49.2 percent in 2015 and 49.1 percent in 2023, a difference of no practical consequence.
Stewardship coverage over the same period moved substantially. Programs were present at 215 of 218 hospitals in 2023, or 98.6 percent, compared with 158 of 199 hospitals, or 79.4 percent, in the earlier survey.
That expansion reflects deliberate policy. Federal officials published core elements for hospital stewardship programs in 2014, a hospital accreditation standard followed in 2017, and the Centers for Medicare and Medicaid Services adopted a rule in 2019 requiring all participating acute-care hospitals to implement such programs. Nearly universal adoption is what those requirements were designed to produce.
The Case That Something Did Change
The counterargument deserves a fair hearing, because a single aggregate figure conceals a good deal.
The antibiotics hospitals reach for have changed markedly. Fluoroquinolone use fell from 9.2 percent to 2.8 percent, a shift researchers link to stewardship efforts and to federal warnings about adverse events with that drug class. Over the same period, use of third- and fourth-generation cephalosporins rose from 12.3 percent to 18.6 percent. That is substitution, not simply reduction, and a survey counting any antibiotic cannot see it.
Specific settings also moved in opposite directions. Antibiotic use in neonatal critical care units fell from 23.4 percent to 17.1 percent, which researchers described as part of a decade-long documented trend they attributed to sepsis risk calculators, diagnostic stewardship and policies targeting early-life antibiotic exposure, without increases in adverse outcomes. Use in mother-baby units rose from 24.4 percent to 32.8 percent. A flat national average can contain real change that cancels out.
Stewardship may also have altered how long antibiotics are given rather than whether they are started. Narrowing therapy once culture results return, shortening durations, and switching from intravenous to oral treatment are all core stewardship activities that improve care without necessarily changing the share of patients on any antibiotic on a given day.
Measuring Volume Instead of Appropriateness
The central limitation is what a point-prevalence survey can and cannot establish.
It counts how many patients received an antibiotic on one day. It does not determine whether each of those prescriptions was appropriate. Some hospital antibiotic use is necessary and appropriate, and no realistic stewardship program would drive the figure toward zero.
Patient mix also changes over eight years. Hospitals increasingly admit only sicker patients, as less acute care shifts to outpatient settings, and a sicker inpatient population would be expected to need more antibiotics. The survey found higher antibiotic use independently associated with critical care and medical-surgical units, the presence of a central line, urinary catheter or ventilator, obesity, and hospital stays of four to 17 days.
The authors themselves cautioned against reading the result as a verdict on stewardship. Given the increasing complexity of inpatient care, they wrote, substantial reductions may be difficult to achieve, and "lower AU prevalence alone may not reflect optimized use." They suggested that targeted efforts focused on specific patient groups and settings are likely to be most useful.
That distinction between having a program and running an effective one is probably the more useful frame for interpreting a flat use rate.
Patient Questions That Fit the Evidence
None of this means a hospitalized patient should question an antibiotic they have been prescribed. In a hospital, antibiotics are frequently the correct treatment, and delays in appropriate therapy cause serious harm. The most common infections treated in both surveys were pneumonia, urinary tract infections, and skin and soft-tissue infections.
The questions that align with what stewardship actually does are about narrowing and duration rather than refusal. Patients or family members can reasonably ask what infection is being treated, whether cultures have returned, whether the antibiotic can be narrowed, how long the course is expected to last, and whether an intravenous antibiotic could be switched to an oral one. Those are the decision points stewardship teams work on.
Nobody should stop or decline a prescribed antibiotic without discussing it with the treating clinician. Accurately reporting a previous antibiotic allergy or reaction matters, since unverified penicillin allergy labels are a well-documented driver of unnecessary broad-spectrum antibiotic use.
The picture outside hospitals differs, and is where individual behavior matters more. Antibiotics do nothing for colds, most sore throats, and most sinus infections, and leftover or borrowed prescriptions should never be taken. More than 2.8 million antimicrobial-resistant infections and over 35,000 deaths occur in the United States each year, according to federal estimates, which is the outcome stewardship exists to slow.
Whether the hospital figure moves in a future survey, and whether appropriateness measures show change that the volume figure misses, are the questions the next round of data will address.
Key Questions Answered
What did the survey find? Just under half of patients at 218 hospitals were receiving an antibiotic on a given day in 2023. Among hospitals surveyed both times, the rate was 49.2 percent in 2015 and 49.1 percent in 2023.
How much did stewardship programs expand? From 79.4 percent of surveyed hospitals in 2015 to 98.6 percent in 2023.
Does this mean stewardship failed? Not necessarily. The survey measured how many patients received antibiotics, not whether the prescriptions were appropriate, and the authors cautioned against that reading.
Did anything change within the data? Yes. Fluoroquinolone use fell from 9.2 percent to 2.8 percent while third- and fourth-generation cephalosporin use rose from 12.3 percent to 18.6 percent, and neonatal critical care use fell while mother-baby unit use rose.
What is the main limitation? A point-prevalence survey counts prescriptions on a single day and cannot judge appropriateness. Hospital patients have also grown sicker over the period.
What should a hospitalized patient do? Do not decline or stop a prescribed antibiotic. Reasonable questions concern what is being treated, whether the drug can be narrowed after cultures, the expected duration, and whether an oral switch is possible.
What matters most outside the hospital? Antibiotics do not treat colds, most sore throats, or most sinus infections, and leftover or borrowed prescriptions should never be used.
