pharmacy Perspective Application of Standardized Antimicrobial Administration Ratio as a Motivational Tool within a Multi-Hospital Healthcare System Stephanie Shealy 1,2,† , Joseph Kohn 2 , Emily Yongue 2 , Casey Troficanto 2 , P. Brandon Bookstaver 1,2 , Julie Ann Justo 1,2 , Hana R. Winders 1,2 , Sangita Dash 3,4 and Majdi N. Al-Hasan 3,4, *   Citation: Shealy, S.; Kohn, J.; Yongue, E.; Troficanto, C.; Bookstaver, P.B.; Justo, J.A.; Winders, H.R.; Dash, S.; Al-Hasan, M.N. Application of Standardized Antimicrobial Administration Ratio as a Motivational Tool within a Multi-Hospital Healthcare System. Pharmacy 2021, 9, 32. https://doi.org/10.3390/ pharmacy9010032 Received: 12 January 2021 Accepted: 3 February 2021 Published: 7 February 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina College of Pharmacy, Columbia, SC 29208, USA; Stephanie.Shealy@imail.org (S.S.); bookstaver@cop.sc.edu (P.B.B.); justoj@cop.sc.edu (J.A.J.); hwinders@cop.sc.edu (H.R.W.) 2 Department of Clinical Pharmacy, Prisma Health–Midlands, Columbia, SC 29203, USA; joseph.kohn@prismahealth.org (J.K.); Emily.Yongue@prismahealth.org (E.Y.); Casey.Troficanto@prismahealth.org (C.T.) 3 Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC 29209, USA; Sangita.Dash@uscmed.sc.edu 4 Department of Medicine, Division of Infectious Diseases, Prisma Health–Midlands, Columbia, SC 29203, USA * Correspondence: majdi.alhasan@uscmed.sc.edu; Tel.: +1-803-540-1062; Fax: +1-803-540-1079 † Stephanie Shealy is currently employed at Intermountain Healthcare in Salt Lake City, UT 84103, USA. Abstract: The standardized antimicrobial administration ratio (SAAR) is a novel antimicrobial stewardship metric that compares actual to expected antimicrobial use (AU). This prospective cohort study examines the utility of SAAR reporting and inter-facility comparisons as a motivational tool to improve overall and broad-spectrum AU within a three-hospital healthcare system. Transparent inter-facility comparisons were deployed during system-wide antimicrobial stewardship meetings beginning in October 2017. Stakeholders were advised to interpret the results to foster competition and incorporate SAAR data into focused antimicrobial stewardship interventions. Student’s t-test was used to compare mean SAARs in the pre- (July 2017 through October 2017) and post-intervention periods (November 2017 through June 2019). The mean pre-intervention SAARs for hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Hospital B experienced significant reductions in SAAR for overall AU (from 1.09 to 0.83; p < 0.001), broad-spectrum antimicrobials used for hospital-onset infections (from 1.36 to 0.81; p < 0.001), and agents used for resistant gram-positive infections in the intensive care units (from 1.27 to 0.72; p < 0.001) after the interventions. The alignment of the SAAR across the health-system and sustained reduction in overall and broad-spectrum AU through implementation of inter-facility comparisons demonstrate the utility in the motivational application of this antimicrobial use metric. Keywords: antibiotics; antimicrobial use; antimicrobial stewardship; metrics 1. Introduction Antimicrobial stewardship programs (ASPs) have long sought a standardized method for benchmarking antimicrobial use, allowing comparative antimicrobial stewardship met- rics between hospitals and assessment of the effectiveness of targeted interventions [1–3]. Traditional facility-specific antimicrobial use metrics include days of therapy, defined daily dose, and antimicrobial cost [4]. Large healthcare systems may be able to internally develop a robust approach to antimicrobial use benchmarking [5]. However, the utility of these tools may be limited in smaller healthcare systems and community hospitals. In response to this need, the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) introduced the standardized antimicrobial administration ratio (SAAR) as a metric included in the antimicrobial use option [6]. The primary objective of the Pharmacy 2021, 9, 32. https://doi.org/10.3390/pharmacy9010032 https://www.mdpi.com/journal/pharmacy