National Antimicrobial Stewardship Performance and Antimicrobial Use in Saudi Ministry of Health Hospitals: A Four-Year Multicenter Surveillance Analysis, 2021–2024

Background/Objectives: Antimicrobial stewardship programmes (ASPs) are essential for improving antimicrobial use and limiting the emergence of antimicrobial resistance. Although national ASP key performance indicators (KPIs) have been implemented across Saudi Ministry of Health (MOH) hospitals, large-scale evaluations of programme performance remain limited. This study evaluated national ASP performance across MOH hospitals from 2021 to 2024 using formal KPIs and complementary stewardship measures. Methods: This retrospective multicentre surveillance analysis included 124,452 antimicrobial prescription reviews from 96 Saudi MOH hospitals actively reporting stewardship activities. Hospitals were classified according to ASP capacity as category A, B, or C. The evaluated KPIs included protocol adherence, restricted-antibiotic dispensing compliance, active intervention rate, annual trends in optimization interventions, and physician acceptance of ASP recommendations. Secondary assessments included appropriateness of therapy management, therapeutic drug monitoring (TDM) for vancomycin and aminoglycosides, and hospital-level antimicrobial use expressed as defined daily doses per 100 available bed-days. Multivariable logistic regression was used to identify factors associated with guideline non-adherence and physician non-acceptance. Results: Overall protocol adherence was 87.1%, exceeding the national target of 80%, while the active intervention rate was 64.6%, exceeding the 60% benchmark. Restricted-antibiotic dispensing compliance reached 87.6% but remained below the 100% target. Physician acceptance of ASP recommendations was high at 93.0%, although it did not achieve the national target of 98%. The optimization-intervention KPI was not met because de-escalation, antibiotic discontinuation, and intravenous-to-oral conversion did not demonstrate a sustained annual increase. Appropriate ongoing therapy management was documented in 68.3% of cases with available data, whereas TDM was requested in 44.5% of eligible vancomycin or aminoglycoside cases. Antimicrobial use varied across years and hospital categories, with higher monitored broad-spectrum and reserve-agent use in higher-capacity hospitals. Lower ASP capacity, non-critical care settings, and combination therapy were consistently associated with less favourable stewardship outcomes. Conclusions: Saudi MOH hospitals actively reporting stewardship activities demonstrated favourable performance in protocol adherence, intervention activity, and physician acceptance. However, persistent gaps in restricted-antibiotic dispensing, optimization interventions, TDM, and inter-hospital variation indicate the need for continued strengthening of ASP infrastructure, monitoring, and feedback systems. Future research should link stewardship indicators with clinical outcomes, antimicrobial resistance trends, and patient safety.