Overview
Antimicrobial stewardship aims to prevent common bacteria becoming resistant to previously effective antibiotics. If growing antibiotic resistance cannot be halted, there’s a risk of minor infections becoming increasingly deadly. The core principles of antimicrobial stewardship include:
- Prescribing the right drug in the correct dose for no longer than necessary
- A commitment to education and training to share knowledge on the importance of collective stewardship
- Ongoing tracking and reporting to monitor changes in resistance.
What is antimicrobial stewardship?
Antimicrobial stewardship, also known as AMS, is a strategy designed to safeguard the efficacy of antimicrobial treatments to prevent more antibiotics becoming resistant to infections. Antimicrobial resistance is an increasing problem, so responsible stewardship is required to safeguard current treatments, while optimising patient outcomes and minimising adverse reactions. The World Health Organization (WHO) sets out antimicrobial stewardship guidelines on a global scale, designed to reduce the threat of AMR around the world.
Effective antimicrobial stewardship requires a coordinated approach from doctors, pharmacists and other healthcare professionals to ensure patients receive the right drug in the right dosage for the optimal duration. AMS is designed to reduce unnecessary exposure to drugs, preventing patients and specific bacteria from developing resistance to life-saving medicines.
The growing threat of antimicrobial resistance
Antimicrobial resistance is the process whereby bacteria and other microbes become resistant to antibiotics that were once able to kill them or halt their growth. AMR is a growing problem, exacerbated by the overprescription and misuse of antibiotics. With no new antibiotic classes discovered for almost four decades, antimicrobial resistance is an increasing threat; if common infections can no longer be treated effectively, we could see people dying following routine surgery or minor infections.
“Without the development of new solutions to combat the risk of bacterial resistance to current antibiotics, we will inevitably return to a pre-antibiotic era. Common medical procedures, such as C-sections or hip replacement surgery, could carry high risks,” explained Professor Timothy Walsh , Research Director at the Ineos Oxford Institute for Antimicrobial Research (IOI).
Government data shows that antimicrobial resistance is a contributing factor in over 35,000 deaths each year in the UK, with this figure likely to rise further as AMR increases. Antimicrobial resistance is not just a problem in the UK; it’s a global threat. A study published in The Lancet titled ‘Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis ’ estimated that 1.27 million deaths worldwide were a direct result of antibiotic resistance in 2019. AMR was also believed to be a contributing factor in 4.95 million deaths globally.
Meanwhile, data from the English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2023-2024 shows that there was a 3.5% increase in the number of antibiotic-resistant bloodstream infections from 2019 to 2023, with E.coli behind more than 65% of the total. The report’s findings indicate that some people are at higher risk than others, with the Asian or Asian British ethnic group recording the highest resistance percentage, with almost 2 in 5 infections resistant to antibiotics, marking an increase from the previous year. All of this highlights the clear need for diligent antimicrobial stewardship.
Core principles of antimicrobial stewardship
There are core principles of antimicrobial stewardship, which are outlined in NICE guidelines , and designed to guide healthcare professionals in making decisions regarding the prescription and monitoring of antimicrobials.
These guidelines can be categorised by the ‘5 Ds’ of antimicrobial stewardship:
- Diagnosis: has the infection been correctly identified? This is crucial to ensuring the most appropriate treatment is prescribed
- Drug: is the right drug being prescribed for the infection?
- Drug route: what’s the best drug delivery route e.g. oral, intravenous, or another method?
- Duration: how long does the course of treatment need to be, without increasing the risk of AMR?
- De-escalation: are you closely monitoring the patient’s response to the therapy to identify when the treatment may need to be more closely targeted or stopped altogether?
Looking at these in more detail, the key principles of antimicrobial stewardship outline:
- Antimicrobials should only be prescribed when it’s determined that there’s a clear clinical need
- The correct drug and dosage should be administered via the shortest yet most effective course
- Guidelines for administering the specific antimicrobial should continue to be followed
- Ongoing surveillance is key. All prescriptions should be documented, with the date, clinical reason, and results of the treatment clearly recorded to monitor any changes in resistance
- Patients should be informed of the risks of antimicrobial resistance, and educated on the correct use of prescribed medications
- Healthcare staff should review the efficacy of a treatment 24 to 48 hours after prescription, and be prepared to de-escalate if necessary
What is not antimicrobial stewardship?
However, it’s important to keep in mind the intentions of antimicrobial stewardship, as there can be some misconceptions regarding its scope.
Most importantly, stewardship is not about reducing the use of antibiotics altogether, but rather getting the prescription and dosage correct. It’s also not about preventing all infections, and it’s not a one-size-fits-all approach; different cases will require tailored interventions.
In addition, antimicrobial stewardship is not just something for pharmacy professionals to be concerned with; healthcare workers at all touchpoints and the general public themselves all have a crucial role to play in tackling antimicrobial resistance.
Challenges associated with antimicrobial stewardship
Antimicrobial stewardship is an important responsibility, and it naturally comes with some challenges. These can include:
- Finding the right balance: getting the right balance between treatment efficacy and preventing antimicrobial resistance is one of the key challenges associated with antimicrobial stewardship. Patient outcomes need to remain a priority, while minimising the risk of AMR worsening in the future
- Education and training: widespread training around antimicrobial stewardship is required across all touchpoints of the healthcare system to ensure everyone is aware of its importance. This requires time, resources and investment, and could lead to delays in training being rolled out in busy healthcare facilities
- Monitoring impact: measuring the success of antimicrobial stewardship measures is vital. The UK is steadily building a standardised AMS data collection ecosystem, anchored by national dashboards, digital system standards, and pilot registries. NHS England and NHS Scotland are leading regionally with structured tools; national strategy provides overarching direction; and targeted studies like UKAR bring deeper, clinical-level insights.
Benefits of effective antimicrobial stewardship
The benefits of effective antimicrobial stewardship can be hugely significant. The difference between success and failure can quite literally be life and death. The key benefits include:
- Reduced antimicrobial resistance: the driving purpose of antimicrobial stewardship is to reduce AMR, subsequently preserving the efficacy of existing antibiotic treatments
- Increased patient safety: antimicrobial stewardship is intended to improve patient outcomes by ensuring everyone receives the most appropriate and effective treatment, with minimal risk of side effects or adverse reactions
- Cost savings: by decreasing the number of drug-resistant infections and reducing the need for or length of hospital stays, successful antimicrobial stewardship can also help healthcare Trusts to save money
- Safeguard future public health: stewardship programmes help ensure that antibiotics continue to work for future generations. Without antimicrobial stewardship efforts, there’s a risk that common infections could prove life-threatening
How to be a responsible antimicrobial steward
As pharmacy professionals, we all have a responsibility to antimicrobial stewardship. To be a responsible steward, you should try to follow these guidelines at all times:
- Do not overprescribe medication or recommend its use unnecessarily
- Advise patients on treating self-limiting conditions where appropriate
- Educate patients on the most effective use of antibiotics, as well as the risks of antimicrobial resistance
- Promote preventative methods, such as the flu vaccine, to help prevent infections requiring antibiotic treatment from spreading
- Share your knowledge with fellow healthcare professionals to make sure everyone’s aware of the importance of antimicrobial stewardship
- Participate in events designed such as World Antimicrobial Awareness Week to increase awareness of AMR and how it can be tackled
- Join a network of fellow antimicrobial stewards to share resources and learnings
The UK government has a toolkit for antimicrobial stewardship , which includes guidance to support compliance with the Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections.
Join the UKCPA Infection Community to tackle AMR
Further your antimicrobial stewardship knowledge and share learnings with fellow pharmacy professionals when you join the UKCPA Infection Community for less than £3 per week. Become a member of our pharmacy community today to access extensive resource libraries, networking events, and infection control forum discussions to continue the battle against antimicrobial resistance.
