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We evaluated whether hospital size modifies the impact of nationally incentivized antimicrobial stewardship programs on clinical and economic outcomes in patients with methicillin-resistant\n                      <jats:italic>Staphylococcus aureus<\/jats:italic>\n                      bloodstream infections.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      This retrospective cohort study analyzed Japanese nationwide claims data from 2018 to 2022. We compared outcomes between adult inpatients with methicillin-resistant\n                      <jats:italic>Staphylococcus aureus<\/jats:italic>\n                      bloodstream infections in large (\u2265\u2009500 beds) versus non-large (&lt;\u2009500 beds) hospitals using 1:1 propensity score matching. The primary outcome was time to discharge. We used an interaction term to assess effect modification by hospital size on the association between antimicrobial stewardship programs and outcomes.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The matched cohort included 926 patients (463 pairs). At baseline, average daily total antimicrobial costs were significantly higher in large hospitals (rate ratio 1.32, 95% CI 1.16\u20131.50). Hospital size significantly modified the association between antimicrobial stewardship programs and time to discharge (P for interaction\u2009=\u20090.01). In non-large hospitals, antimicrobial stewardship programs were associated with significantly shorter time to discharge (hazard ratio 0.31, 95% CI 0.13\u20130.75). In large hospitals, antimicrobial stewardship programs were not associated with time to discharge but were associated with significantly reduced average daily antipseudomonal drug costs (rate ratio 0.46, 95% CI 0.30\u20130.71).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>\n                      Hospital size modified the association between antimicrobial stewardship program fee acquisition and outcomes among patients with methicillin-resistant\n                      <jats:italic>Staphylococcus aureus<\/jats:italic>\n                      bloodstream infections. In non-large hospitals, antimicrobial stewardship program fee acquisition was associated with shorter time to discharge, whereas in large hospitals, it was primarily associated with changes in prescribing patterns. These findings suggest that stewardship evaluation and policy should be tailored to institutional characteristics.\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40780-026-00558-2","type":"journal-article","created":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T02:14:12Z","timestamp":1772072052000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Modifying effect of hospital size on the impact of antimicrobial stewardship programs for methicillin-resistant Staphylococcus aureus bloodstream infections: a nationwide claims database analysis"],"prefix":"10.1186","volume":"12","author":[{"given":"Keisuke","family":"Sawada","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryo","family":"Inose","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuichi","family":"Muraki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,26]]},"reference":[{"issue":"2","key":"558_CR1","doi-asserted-by":"publisher","first-page":"131","DOI":"10.53854\/liim-3202-2","volume":"32","author":"SS Adeiza","year":"2024","unstructured":"Adeiza SS, Aminul I. 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J Antimicrob Chemother. 2022;77(8):2130\u201341. https:\/\/doi.org\/10.1093\/jac\/dkac154.","journal-title":"J Antimicrob Chemother"}],"container-title":["Journal of Pharmaceutical Health Care and Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s40780-026-00558-2","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40780-026-00558-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40780-026-00558-2.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,16]],"date-time":"2026-06-16T18:53:36Z","timestamp":1781636016000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s40780-026-00558-2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,26]]},"references-count":41,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["558"],"URL":"https:\/\/doi.org\/10.1186\/s40780-026-00558-2","relation":{},"ISSN":["2055-0294"],"issn-type":[{"value":"2055-0294","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,26]]},"assertion":[{"value":"11 December 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 February 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 February 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was approved by the Kyoto Pharmaceutical University Ethics Committee (exemption number: NR-00006). The requirement for individual informed consent was waived because the database consists of fully anonymized data.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"RI received funding for commissioned research from Kowa Company, Ltd. YM received grants from Pfizer Japan Inc., Kowa Company Ltd., the Japan Pharmaceutical Association, and the Ministry of Health, Labor and Welfare. YM is a board member of the Japanese Society of Pharmaceutical Health Care and Sciences and the Japanese Society for Infection Prevention and Control and a committee member of the AMR Clinical Reference Center. The authors declare that they have no other competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"39"}}