Paper long abstract:

"Optimizing antibiotic use" is an increasingly visible terminology used in policy documents to refer to interventions to improve antibiotic prescription in clinical settings. Often understood in contraposition to or going beyond antibiotic "stewardship" interventions, optimization intervention projects are increasingly finding support by policymakers across Spanish-speaking contexts particularly, where these clinical interventions are referred to as "Programas de Optimización de Antimicrobianos" or by their acronym, PROA. In Spain, hospital PROAs are a major AMR national policy priority; to this day, it remains without a state budget.

Whilst the principle of optimization drug use seems straight-forward when found in policy documents, grappling with how it is achieved, its subtle meanings, how it might (or not) be different from "stewardship", or what (human and material) resources it requires (and currently lacks) are at the heart of the online interviews I have carried out with Spanish PROA leaders based in public hospitals (of all sizes in a wide range of geographies in Spain) during 2021.

In this paper, I will address the gratifying moments, awkward silences, seemingly ready-made blurbs and repetitions, and subtle denouncements I have encountered when asking clinicians (mostly based in hospital infectious disease services), nurses, hospital pharmacists, and clinical microbiologists about the notion of optimization in PROAs. I will show some hints to the complex politics of hospital PROAs that have arisen when analyzing these PROA leaders' accounts of optimizing antibiotic use, including aspects such as the lack of public resources, or the ongoing nationalising and standardising processes of PROA interventions.