Thank you very much for an excellent question.
Stewardship is the way. Stewardship, of course, is a broad category of different interventions. We believe the most effective is a fairly labour-intensive intervention called prospective audit with intervention and feedback. Antimicrobial orders in hospital are reviewed by a specialized team, typically consisting of a pharmacist and often an infectious disease physician in larger hospitals or another physician. There is a conversation with prescribing physicians and nurse practitioners about the reasons for the antibiotic prescription that was given and suggestions of alternative options. The long-term effect of this small iterative nudges toward a more appropriate prescribing and a more educated health care workforce with better overall usage data.
In fact, there are studies increasingly demonstrating better resistance data. Typically, though, antimicrobial stewardship programs tend to run on what we call process metrics. How many defined daily doses of antibiotic X are used per day in the hospital? It's really hard for a hospital to be able to demonstrate a difference. You usually need large datasets and big research networks to be able to demonstrate the long-term effects.
As Dr. Dhami has said, when you're looking just at the acute-care hospitals, which is really where stewardship is done right now, you're missing the boat. There are about 66,000 beds in acute-care hospitals across Canada. There are 200,000 long-term care beds and multiple outpatient prescriptions, as well. We do not have effective programs for stewardship in long-term care or in the community.