BACKGROUND: Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world. METHODS: A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery. RESULTS: The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%). CONCLUSION: The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

1st Department of Surgery Department of Abdominal Thoracic Surgery and Traumatology General University Hospital Prague Czech Republic

1st Department of Surgery Tzaneion General Hospital Piraeus Greece

2nd Department of General Surgery Jagiellonian University Medical College Krakow Poland

2nd Department of Surgery Aretaieion University Hospital National and Kapodistrian University of Athens Athens Greece

2nd Surgical Clinic Emergency Hospital of Craiova Craiova Romania

3rd Department of General Surgery Jagiellonian University Medical College Krakow Poland

4th Department of Internal Medicine and Infectious Diseases Unit National and Kapodstrian University Medical School Attikon University General Hospital Athens Greece

4th Surgical Department General Hospital G Papanikolaou Medical School Aristotle University of Thessaloniki Thessaloniki Greece

Abdominal Center University Hospital Meilahti Helsinki Finland

Academic Department of Surgery Queen Elizabeth Hospital Birmingham UK

Burns Trauma and Critical Care Research Centre The University of Queensland Brisbane Queensland Australia

Center for Critical Care Anaesthesiology Institute and Department of Outcomes Research Cleveland Clinic Cleveland OH USA

Center for Global Health Mito Kyodo General Hospital University of Tsukuba Mito Ibaraki Japan

Center of Anti Infective Research and Development Hartford CT USA

Clinic for Emergency Surgery Medical Faculty University of Belgrade Belgrade Serbia

Clinic for General Surgery Clinical Centre Nis Serbia

Clinical Epidemiology Unit IRCCS Policlinico San Matteo Foundation Pavia Italy

Clinical Microbiology and Infectious Diseases School of Pathology Faculty of Health Sciences University of the Witwatersrand Johannesburg South Africa

Clinical Research Center Fundacion Valle del Lili Cali Colombia

Department for Traumatology and Orthopedic Surgery Cologne Merheim Medical Center Cologne Germany

Department General Surgery Kipshidze Central University Hospital Tbilisi Georgia

Department of Abdominal Surgery Regional Hospital of Tienen Tienen Belgium

Department of Abdominal Surgery Vladimir City Clinical Hospital of Emergency Medicine Vladimir Russia

Department of Aeromedical Services for Emergency and Trauma Care Ehime University Graduate School of Medicine Ehime Japan

Department of Antibiotics and Infection Control Rudolfstiftung Hospital Vienna Austria

Department of Biomedical Sciences and Public Health Unit of Hygiene Preventive Medicine and Public Health Università Politecnica delle Marche Ancona Italy

Department of Clinical Medicine University of Bergen Bergen Norway

Department of Clinical microbiology Ampath National Laboratory Services Milpark Hospital Johannesburg South Africa

Department of Critical Care Medicine Ghent University Hospital Ghent Belgium

Department of Digestive Surgery Cannes Hospital Cannes France

Department of Emergency Surgery and Critical Care Centro Medico Imbanaco Cali Colombia

Department of Emergency Surgery City Hospital Mozyr Belarus

Department of Emergency Umberto 1 Hospital Rome Italy

Department of Gastrointestinal Surgery Santa Casa Hospital Campo Grande Brazil

Department of Gastrointestinal Surgery Stavanger University Hospital Stavanger Norway

Department of General and Emergency Surgery Riga East University Hospital 'Gailezers' Riga Latvia

Department of General and Emergency Surgery University Hospital Kraków Kraków Poland

Department of General and Thoracic Surgery University Hospital Giessen Giessen Germany

Department of General Surgery Erzincan University Faculty of Medicine Erzincan Turkey

Department of General Surgery Health Sciences University Samsun Training and Research Hospital Samsun Turkey

Department of General Surgery Hospital San Juan de Dios de La Serena La Serena Chile

Department of General Surgery Jesenice General Hospital Jesenice Slovenia

Department of General Surgery Kuala Krai Hospital Kuala Krai Kelantan Malaysia

Department of General Surgery Maggiore Hospital Parma Italy

Department of General Surgery Mansoura Faculty of Medicine Mansoura University Mansoura Egypt

Department of General Surgery Tan Tock Seng Hospital Tan Tock Seng Singapore

Department of Infectious Diseases John Peter Smith Health Network Fort Worth Texas USA

Department of Internal Medicine and Infectious Diseases University of Cologne Cologne Germany

Department of Internal Medicine National Cheng Kung University Hospital Tainan Taiwan

Department of Internal Medicine Royal Hospital Muscat Oman

Department of Internal Medicine Seoul National University Bundang Hospital Seongnam Republic of Korea

Department of Medicine Division of Infectious Diseases University of South Carolina School of Medicine Columbia SC USA

Department of Medicine Infectious Disease Division King Fahad Medical City Riyadh Saudi Arabia

Department of Medicine Northeast Ohio Medical University Rootstown OH USA

Department of Microbiology Bicêtre Hospital Paris Sud University La Kremlin Bicêtre France

Department of Microbiology Gandhi Medical College Bhopal India

Department of Microbiology Grande International Hospital Dhapasi Kathmandu Nepal

Department of Microbiology National Reference Laboratory Cheikh Khalifa Ibn Zaid Hospital Mohammed 6th University of Health Sciences Casablanca Morocco

Department of Microbiology Tribhuvan University Teaching Hospital Institute of Medicine Kathmandu Nepal

Department of Molecular Biology Tran Hung Dao Hospital No 1 Tran Hung Dao Street Hai Ba Trung Dist Hanoi Vietnam

Department of Pathology and Laboratory Medicine Boston University School of Medicine Boston MA USA

Department of Pathology and Laboratory Medicine VA Boston HealthCare System Boston MA USA

Department of Pharmacology and Therapeutics College of Health Sciences Makerere University Kampala Uganda

Department of Pharmacology Postgraduate Institute of Medical Education and Research Chandigarh India

Department of Pharmacology Pushpagiri Institute of Medical Sciences and Research Centre Thiruvalla Kerala India

Department of Pharmacy Lebanese International University Beirut Lebanon

Department of Primary Care and Emergency Medicine Kyoto University Graduate School of Medicine Kyoto Japan

Department of Surgery and Critical Care Universidad del Valle Fundación Valle del Lili Cali Colombia

Department of Surgery and Obstetrics Gynaecology Regional Hospital Limbe Cameroon

Department of Surgery Bharati Vidyapeeth Deemed University Medical College and Hospital Sangli Maharashtra India

Department of Surgery Clinica Foianini Santa Cruz Bolivia

Department of Surgery College of Health Sciences Obafemi Awolowo University Ile Ife Nigeria

Department of Surgery College of Medicine and Health Sciences UAE University Al Ain United Arab Emirates

Department of Surgery Division of Trauma University of Arizona Tucson AZ USA

Department of Surgery Emergency Hospital of Bucharest Bucharest Romania

Department of Surgery Faculty of Medicine Thammasat University Hospital Thammasat University Pathum Thani Thailand

Department of Surgery Faculty of Medicine University of Parakou BP 123 Parakou Benin

Department of Surgery Hospital Clínico Universitario Santiago de Compostela Spain

Department of Surgery Infermi Hospital Rimini Italy

Department of Surgery Inling Hospital Nanjing University School of Medicine Nanjing China

Department of Surgery John Peter Smith Health Network Fort Worth Texas USA

Department of Surgery King Abdullah University Hospital Irbid Jordan

Department of Surgery Macerata Hospital Macerata Italy

Department of Surgery Maggiore Hospital Bologna Italy

Department of Surgery Medical School University of Pécs Pécs Hungary

Department of Surgery Medical University of Graz Graz Austria

Department of Surgery n 2 Higher educational institutions of Ukraine Bukovina State Medical University Chernivtci City Ukraine

Department of Surgery North Estonia Medical Center Tallinn Estonia

Department of Surgery Onandjokwe Hospital Ondangwa Namibia

Department of Surgery Philadelphia VA Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia PA USA

Department of Surgery Post Graduate Institute of Medical Sciences Rohtak India

Department of Surgery Radboud University Nijmegen Medical Center Nijmegen The Netherlands

Department of Surgery Radiology University Hospital of the West Indies Kingston Jamaica

Department of Surgery Santa Casa de Sao Paulo School of Medical Sciences São Paulo Brazil

Department of Surgery School of Medicine Pontifícia Universidade Católica do Rio Grande do Sul Porto Alegre Brazil

Department of Surgery Tianjin Nankai Hospital Nankai Clinical School of Medicine Tianjin Medical University Tianjin China

Department of Surgery Universidad Nacional de Asuncion Asuncion Paraguay

Department of Surgery University Hospital Center Zagreb Croatia

Department of Surgery University Hospital of Trauma Tirana Albania

Department of Surgery University of Campinas Campinas Brazil

Department of Surgery University of Colorado Denver Health Medical Center Denver CO USA

Department of Surgery University of Michigan Ann Arbor MI USA

Department of Surgery University of Pittsburgh Pittsburgh PA USA

Department of Surgery University of Sao Paulo Ribeirao Preto Brazil

Department of Surgery University of Virginia Health System Charlottesville VA USA

Department of Surgery Vanderbilt University Medical Center Nashville Tennessee USA

Department of Surgery Versilia Hospita Lido di Camaiore Italy

Department of Surgery Virginia Commonwealth University Richmond VA USA

Department of Surgery Weill Cornell Medicine New York NY USA

Department of Surgery Yonsei University College of Medicine Seoul South Korea

Department of Trauma Hospital Santo Tomas Panama Panama

Department of Urology Pediatric Urology and Andrology Medical Faculty of the Justus Liebig University Giessen Giessen Germany

Departments of Medicine Clinical Epidemiology and Biostatistics and Pathology and Molecular Medicine McMaster University Hamilton ON Canada

Division of Acute Care Surgery Department of Surgery University of Michigan Ann Arbor MI USA

Division of Clinical and Administrative Sciences College of Pharmacy Xavier University of Louisiana New Orleans LA USA

Division of Infectious Diseases American University of Beirut Beirut Lebanon

Division of Infectious Diseases and HIV Medicine Department of Medicine University of Cape Town Cape town South Africa

Division of Infectious Diseases Cleveland Clinic Akron General Akron OH USA

Division of Infectious Diseases Division of Emergency Medicine Washington University School of Medicine St Louis MO USA

Division of Infectious Diseases Jackson Health System University of Miami Miller School of Medicine Miami FL USA

Division of Trauma and Surgical Critical Care DeWitt Daughtry Family Department of Surgery University of Miami Miami FL USA

Drug Applied Research Center Tabriz University of Medical Sciences Tabriz Iran

Emergency Post operative Department Otavio de Freitas Hospital and Hosvaldo Cruz Hospital Recife Brazil

Eric Williams Medical Sciences Complex Uriah Butler Highway Champ Fleurs Trinidad and Tobago

General and Upper GI Surgery Queen Elizabeth Hospital Birmingham UK

General Surgery Department Bakirkoy Dr Sadi Konuk Training and Research Hospital Instanbul Turkey

General Surgery Department Medical University University Hospital St George Plovdiv Bulgaria

General Surgery Department Papa Giovanni XXIII Hospital Bergamo Italy

Health Research Program Institute of Economic and Social Research University of Zambia Lusaka Zambia

Hospital Center Tondela Viseu Tondela Portugal

Hospital Central Dr Ignacio Morones Prieto San Luis Potosi Mexico

Hospital Epidemiology and Infectious Diseases Hospital Universitario Dr Jose Eleuterio Gonzalez Monterrey Mexico

Infection Control Committee Prontobaby Hospital da Criança Rio de Janeiro Brazil

Infection Control Unit Angers University CHU d'Angers Angers France

Infectious and Tropical Diseases Department University Hospital of Nancy and EA 4360 APEMAC Lorraine University Nancy France

Infectious Diseases Division Department of Medicine Prince Mohamed Bin Abdulaziz Hospital Ministry of Health Riyadh Saudi Arabia

Infectious Diseases Division Warren Alpert Medical School of Brown University Rhode Island Hospital Providence RI USA

Infectious Diseases Unit Bolzano Central Hospital Bolzano Italy

Infectious Diseases Unit Department of Medical and Surgical Sciences Sant'Orsola Hospital University of Bologna Bologna Italy

Institute of Infectious Diseases Catholic University Rome Italy

Intensive Care Medicine Department Centro Hospitalar São João University of Porto Porto Portugal

John Farman Intensive Care Unit University Hospitals NHS Foundation Trust Cambridge UK

JPS Health Network Texas TX USA

Laboratory of Clinical Microbiology Department of Infectious Diseases Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City Mexico

National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance Imperial College London Hammersmith Campus London UK

Niguarda Hospital Milano Italy

Office of Hospital Epidemiology Infection Prevention and Control University of Virginia Health System Charlottesville VA USA

Peruvian Navy Medical Center Lima Peru

School of Pharmacy and Biomedicine Mongolian National University of Medical Sciences Ulaanbaatar Mongolia

School of Pharmacy Faculty of Medical Sciences The University of the West Indies St Augustine Trinidad and Tobago

Section of Critical Care Medicine and Section of Infectious Diseases Department of Medicine Medical Microbiology and Pharmacology Therapeutics University of Manitoba Winnipeg MB Canada

Service of General Surgery Hospital Complex of Jaén Jaén Spain

Servicio de Anestesia y Reanimación Hospital Universitario La Paz Madrid Madrid Spain

Sixth Department of Internal Medicine Hygeia General Hospital Athens Greece

State Key Laboratory for Diagnosis and Treatment of Infectious Diseases The 1st Affilliated Hospital Zhejiang University Zhejiang China

Sudan National Public Health Laboratory Federal Ministry of Health Khartoum Sudan

Texas Tech University Health Sciences Center School of Pharmacy Abilene TX USA

Trauma and Acute Care Service St Michael's Hospital University of Toronto Toronto Canada

Trauma and Acute Care Surgery Unit Hadassah Hebrew University Medical Center Jerusalem Israel

Trauma and Emergency Surgery Department Chang Gung Memorial Hospital Taoyuan City Taiwan

Trauma and Trauma ICU Inkosi Albert Luthuli Central Hospital and Department of Surgery University of KwaZulu Natal Durban South Africa

Unidad Clínica Intercentros de Enfermedades Infecciosas Microbiología y Medicina Preventiva Hospitales Universitarios Virgen Macarena y Virgen del Rocío IBiS and Departamento de Medicina Universidad de Sevilla Seville Spain

Unit of Hospital Pharmacy Macerata Hospital Macerata Italy

Unit of Prevention and Infection Control Center of Hospital Epidemiology São João Hospital Centre Porto Portugal

University Department for Tumours Sestre Milosrrdnice UHC Zagreb Croatia

VU University Medical Center Amsterdam The Netherlands

World Alliance against Antibiotics Resistance Rome Italy

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