BACKGROUND:
Antimicrobial stewardship programs (AMS) are central to addressing antimicrobial resistance. Assessment of AMS implementation, however, relies on tools that differ substantially in scope, content, and intended use. This heterogeneity raises concerns regarding inclusion, equity, and the capacity of diverse health systems, particularly those operating under resource constraints, to engage in stewardship evaluation, comparison, and global benchmarking. To better understand this landscape we mapped and compare tools used to assess the implementation of hospital-based antimicrobial stewardship programs, focusing on how assessment approaches accommodate diversity in health system capacity and context.

METHODS:
We conducted a comparative review of peer-reviewed studies and policy documents published between 2011 and 2024 that applied structured tools to assess AMS implementation in inpatient hospital settings. Five electronic databases and relevant grey literature sources were searched. Identified tools were examined by origin, scope, assessed components, geographic application, and alignment with internationally recognized AMS domains.

RESULTS:
Twenty-four documents met inclusion criteria, identifying twelve distinct AMS assessment tools developed by international, national, and facility-level institutions. Globally endorsed frameworks, including WHO toolkits and the CDC Core Elements, were most frequently used. Core domains—such as leadership commitment, education and training, and stewardship actions—were consistently assessed. In contrast, domains critical for inclusive implementation, including public awareness, pharmacy expertise, information technology capacity, surveillance infrastructure, and resource allocation, were inconsistently captured. Local adaptations were common but varied widely across settings

CONCLUSIONS:
Current AMS assessment practices reveal an imbalance between standardization and contextual adaptation. While some tools support comparability, resource-intensive assessment frameworks may exclude health systems with limited resources or differing organizational structures. More inclusive and complementary approaches are to balance global alignment with local context. Combining complementary global and locally adapted tools may offer a pragmatic pathway toward equitable stewardship evaluation, meaningful participation across diverse health systems, while supporting global learning and policy development.