Background Antibiotics are among the most frequently administered drugs globally, yet they are often prescribed inappropriately. Guidelines for prescribing are developed by expert committees at international and national levels to form regional standards and by local experts to form hospital guidance documents. Our aim was to assess variability in antibiotic prescription guidelines for both regional standards and individual hospitals. Methods A search through 3 publicly accessible databases from February to June 2018 led to a corpus of English language guidance documents from 70 hospitals in 12 countries and regional standards from 7 academic societies. Results Guidelines varied markedly in content and structure, reflecting a paucity of rules governing their format. We compared recommendations for 3 common bacterial infections: community-acquired pneumonia, urinary tract infection, and cellulitis. Hospital guidance documents and regional standards frequently disagreed on preferable antibiotic classes for common infections. Where agreement was observed, guidance documents appeared to inherit recommendations from their respective regional standards. Several regional prescribing patterns were identified, including a greater reliance on penicillins over cephalosporins in the United Kingdom and fluoroquinolones in the United States. Regional prescribing patterns could not be explained by antibiotic resistance or costs. Additionally, literature that cited underlying recommendations did not support the magnitude of recommendation differences observed. Conclusions The observed discordance among prescription recommendations highlights a lack of evidence for superior treatments, likely resulting from a preponderance of noninferiority trials comparing antibiotics. In response, we make several suggestions for developing guidelines that support best practices of antibiotic stewardship.

BackgroundThe accrediting institution for hospitals in the United States made antimicrobial stewardship programs (ASPs) mandatory in 2017. In part due to the relatively new status of ASPs, standards surrounding the content produced by these programs are still in their infancy. One product of ASPs are antibiotic prescription guidelines, which vary greatly across hospitals in terms of their structure and content.MethodsIn this study, we reviewed 70 publicly available antibiotic prescription guidelines published from 2006 to 2017, originating from 12 countries on four continents to evaluate their coverage and variability.ResultsGuidelines varied greatly in terms of their length, word count, page layout, revision frequency, and number of contributing authors. In terms of content, guidelines were discordant in their inclusion of cost information, restricted antibiotics, disclaimers, and pediatric recommendations. Guidelines also varied in their approach, in that some were focused on how to approach specific diagnoses, while others were focused on the usage of particular antibiotics. Many guidelines made use of decision trees to convey information, especially for the diagnosis and treatment of Clostridium difficile-associated diarrhea, cellulitis, and community-acquired pneumonia; however, the number of decision trees included in a hospital’s guideline varied greatly. A small minority of guidelines included identification trees for classifying bacterial isolates. Guidelines also notably differed in the extent to which they incorporated local antibiotic susceptibility data. Some guidelines did not report antibiogram summaries, while others displayed information for 5 to 34 organisms. Furthermore, we assessed guidelines’ prescription recommendations for 12 common bacterial infections and found large variation in suggested prescribing practices across hospitals.ConclusionTo our knowledge, this study provides the first large-scale analysis of antibiotic prescription guidelines and highlights the extreme variation in approaches to stewardship across hospitals. Furthermore, our analysis provides a baseline of current practices for future comparison, and initiates a discussion into what comprises a model antibiotic prescription guideline.Disclosures All authors: No reported disclosures.