Antibiotic stewardship programmes: legal framework and structure and process indicator in Southwestern French hospitals, 2005-2008.

French hospitals are required to implement antibiotic stewardship programmes (ABS) to improve antibiotic use. We analysed the legal framework on ABS and assessed its impact on hospitals' ABS development in Southwestern France. For each official text, required measures, date of issue, means of control and incentives were analysed. Annual retrospective surveys were conducted in 84 hospitals from 2005 to 2008 to monitor implementation of ABS components: organisation, resources and actions. Evolution of individual measures and of a structure and process indicator (SPI) reflecting ABS was described for each hospital. From 2002, official texts issued by health authorities set out requirements on ABS, based on previous professional guidelines. Incentives and means of control were reinforced in 2006 and in 2007 with mandatory reporting of SPI for public disclosure. ABS implementation improved during the course of the study period. In 2008, at least 98% of hospitals had implemented formularies, antibiotic committees, surgical prophylaxis guidelines, and monitored antibiotic use; antibiotic advisors were appointed in 85% of hospitals. Little progress was made regarding time dedicated by pharmacists to antibiotic management and restrictive dispensation using stop-orders. Computerised tools, continuing education and audits remained under-used. SPI values were higher in private hospitals and rehabilitation centres than in others. Official texts and the SPI public disclosure increased professionals' and hospital managers' commitment to develop ABS, resulting in improvements. However, some actions still need to be reinforced. It appears crucial to monitor practical implementation to better approach ABS effectiveness and to adapt requirements.