International Journal of Advance Research Publication and Reviews

International Journal of Advance Research Publication and Reviews
Peer-Reviewed | Multi-Disciplinary Journal

ISSN: 3049-0103 (O)

Impact Factor: 4.33

Defined Daily Dose and Days of Therapy for Monitoring Antibiotic Consumption: A Narrative Review

Author

Hithesh Saligrama Rudrachala, Anu Shashidhara, Shreyas Ramasamudra Venkatesha, Harshith Gowda Mysore Nagendra, Dr. Sheba Baby John, Bettaswamy Huraliganaganahalli Vykuntappa, Hanumantachar Joshi

Abstract

 Background: The escalating threat of antimicrobial resistance (AMR) has rendered the implementation of robust Antimicrobial Stewardship Programs (ASPs) a global priority. Central to these programs is the systematic monitoring of antibiotic utilization; however, selecting the appropriate quantitative metrics remains a significant clinical and technical challenge.

Objective: This narrative review aims to critically analyze and synthesize the evidence regarding the two primary metrics for monitoring antibiotic consumption: the Defined Daily Dose (DDD) and Days of Therapy (DOT). The review evaluates their methodological foundations, clinical applicability, and the implications of their discordance for stewardship outcomes.

Methods: A comprehensive literature search was conducted across PubMed, Scopus, and the Web of Science for studies published up to April 2026. Eligibility criteria focused on peer-reviewed research evaluating the application, comparison, or limitations of DDD and DOT within various healthcare settings. A narrative and thematic synthesis approach was employed to examine the evidence across ten included studies.

Results: The synthesis reveals that the DDD—a standardized unit developed by the World Health Organization—is the gold standard for longitudinal benchmarking and international surveillance due to its stability. However, it often fails to account for patient-specific dosing, such as weight-based requirements in pediatrics or renal adjustments in intensive care. Conversely, the DOT provides a more clinically intuitive and accurate reflection of actual antimicrobial exposure at the bedside. The literature highlights a consistent "metric-patient mismatch," where the discordance between DDD and DOT can lead to conflicting interpretations of stewardship efficacy, potentially creating perverse incentives that favor lower-dose, suboptimal therapies.

Conclusion: Neither the DDD nor the DOT should be viewed as a standalone solution. The DDD is essential for macro-level surveillance and policy benchmarking, while the DOT is the superior tool for micro-level, patient-centric clinical stewardship. This review proposes a dual-metric approach, supported by automated electronic clinical decision support systems, to provide a balanced dashboard for quality improvement. Standardizing the application of both metrics is critical for mitigating the risk of AMR and ensuring the long-term efficacy of antibiotic therapies across diverse clinical environments.


Keywords

Antimicrobial Stewardship; Antibiotic Utilization; Defined Daily Dose; Days of Therapy; Antimicrobial Resistance; Surveillance Metrics.

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References

  1. Misra, A. K., et al. (2023). Defined daily dose (DDD): An essential metric in the antimicrobial stewardship programmes (AMSPs) in the healthcare sector. Journal of Antimicrobial Stewardship Practice, 1(1), 1–8.
  2. Centers for Disease Control and Prevention. (2026). Antimicrobial resistance: Global public health threat.
  3. Madaras-Kelly, K. J., et al. (2014). Antimicrobial stewardship programs: Appropriate measures and metrics to study their impact. Pharmacotherapy, 34(11), 1145–1155.
  4. World Health Organization. (2023). Guidelines for ATC classification and DDD assignment.
  5. Kuster, S. P., et al. (2022). Defining and measuring antimicrobial use: A gap between DDD and DOT. Clinical Microbiology and Infection, 28(6), 790–799.
  6. Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71.
  7. Higgins, J. P., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M. J., et al. (2019). Cochrane handbook for systematic reviews of interventions (2nd ed.). John Wiley & Sons.
  8. World Health Organization. (2019). Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. WHO.
  9. World Health Organization. (2026). Guidelines for ATC classification and DDD assignment (2026 ed.). WHO Collaborating Centre for Drug Statistics Methodology.
  10. Polk, R. E., Fox, C., Mahoney, A., Letcavage, J., & Thompson, D. (2007). Measurement of adult antibacterial drug use in 130 US hospitals: Comparison of defined daily dose and days of therapy. Clinical Infectious Diseases, 44(5), 664–670.
  11. Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., et al. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ, 350, g7647.
  12. Barlam, T. F., Cosgrove, S. E., Abbo, L. M., MacDougall, C., Schuetz, A. N., Septimus, E. J., et al. (2016). Implementing an antibiotic stewardship program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clinical Infectious Diseases, 62(10), e51–e77.
  13. Higgins, J. P., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414), 557–560.
  14. Polk, R. E., Fox, C., Mahoney, A., Letcavage, J., & MacDougall, C. (2007). Measurement of adult antibacterial drug use in 130 US hospitals: Comparison of defined daily dose and days of therapy. Clinical Infectious Diseases, 44(5), 664–670.
  15. Morris, A. M. (2014). Antimicrobial stewardship programs: Appropriate measures and metrics to study their impact. Current Treatment Options in Infectious Diseases, 6(2), 101–112.
  16. Guillot, J., Lebel, D., Roy, H., Ovetchkine, P., & Bussières, J. F. (2014). Usefulness of defined daily dose and days of therapy in pediatrics and obstetrics-gynecology: A comparative analysis of antifungal drugs. Journal of Pediatric Pharmacology and Therapeutics, 19(3), 196–201.
  17. Momattin, H., Al-Ali, A. Y., Mohammed, K., & Al-Tawfiq, J. A. (2018). Benchmarking of antibiotic usage: An adjustment to reflect antibiotic stewardship program outcome in a hospital in Saudi Arabia. Journal of Infection and Public Health, 11(3), 310–313.
  18. Ahmed, M. N. (2025). Assessment of antibiotic utilization patterns in an Indian Level-1 Trauma Center: A pilot study exploring days of antibiotic spectrum coverage and defined daily doses. Frontiers in Antibiotics, 4, 1578217.
  19. Misra, A. K., et al. (2023). Defined daily dose (DDD): An essential metric in the antimicrobial stewardship programmes (AMSPs) in the healthcare sector. Journal of Antimicrobial Stewardship Practice, 1(1), 1–8.
  20. Moras, W. D. (2026). Evaluation of antibiotic consumption and resistance patterns among neonates: A 10-year retrospective study. Frontiers in Pediatrics, 14, 1774875.
  21. Kuster, S. P., et al. (2022). Defining and measuring antimicrobial use: A gap between DDD and DOT. Clinical Microbiology and Infection, 28(6), 790–799.
  22. Llor, C., et al. (2021). Monitoring antibiotic use in primary care: The role of DDD. Family Practice, 38(4), 450–456.
  23. Filice, G. A., et al. (2020). Implementation of Days of Therapy (DOT) as a feedback mechanism in intensive care. Journal of Hospital Infection, 105(2), 220–225.

 

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