Antimicrobial resistance is a global threat, directly affecting Brazil. Antimicrobial Stewardship Programs (ASPs) are essential to optimize the use of antimicrobials (AMBs), reduce costs, and minimize resistance. This study describes the profile of Brazilian hospitals without ASPs, identifying challenges and opportunities.

This is a cross-sectional sub-analysis of the national survey conducted between October 2022 and January 2023 by the National Health Surveillance Agency (ANVISA) and partner institutions. The convenience sample included 2,073 hospitals (27.7%) from all regions of the country, of which 584 (28.1%) did not have ASPs. Variables analyzed included hospital size (small, medium, large), location (capital/interior), presence of infection control programs, microbiology laboratories, and reasons for lack of ASPs. Statistical analysis was performed using SPSS R version 28.m.

Among the 584 hospitals without ASPs, 195 (33.4%) did not perform any actions regarding antimicrobial use. About 18% also lacked an active hospital infection control program. Of these, 30.1% had outsourced microbiology laboratories; 96% were small hospitals, and 86.7% were located in the interior. The shortage of specialized professionals was the main barrier to ASP implementation. The absence of specific actions for antimicrobial use represents a critical gap, even with national guidelines already published. The lack of structure, especially in small and rural hospitals, compromises patient safety and contributes to the spread of resistant bacteria. These findings highlight the urgent need for targeted interventions and public policies to strengthen health infrastructure.

The study reveals significant challenges in implementing ASPs, particularly in hospitals outside major urban centers. Overcoming these barriers is crucial to strengthening the healthcare system as a whole, especially in the current global context of a “One Health” approach.