Letter to the Editor: From antibiotic exposure to antibiotic intensity: Rethinking inpatient stewardship in inflammatory bowel disease

The study by Zeng et al, published in the recent issue of the World Journal of Gastroenterology, present a 10-year real-world analysis of antibiotic use among hospitalized patients with inflammatory bowel disease (IBD) (2015-2024) and provide probabilistic forecasts through 2027. Their data highlight a pivotal stewardship message: Antibiotic exposure prevalence and antibiotic consumption intensity are not interchangeable metrics. Although the proportion of admissions receiving antibiotics declined in 2020-2024 compared with 2015-2019, antibiotic consumption intensity (DDD/100 bed-days) increased significantly, accompanied by a recent rise in broad-spectrum and traditionally “last-resort” agents, including carbapenems and vancomycin. Antibiotic-exposed admissions clustered in older patients and were associated with longer length of stay and higher costs, suggesting that antibiotic burden concentrates in high-acuity episodes rather than being evenly distributed across the inpatient IBD population. The forecasting component showed wide uncertainty but consistently indicated upward pressure on antibiotic burden if current practices and policies remain unchanged. This letter argues that inpatient stewardship in IBD should pivot from counting “exposed admissions” to monitoring intensity, escalation patterns, and indication-specific use, and proposes an IBD-tailored stewardship roadmap integrating diagnostic stewardship, standardized perioperative and intra-abdominal infection pathways, early reassessment with de-escalation, and structured metrics to curb avoidable escalation while preserving clinical outcomes.