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Antimicrobial Stewardship

Implementing an antibiotic stewardship programme in all healthcare facilities is crucial to promoting appropriate use (NICE 2016) and includes defining the right antibiotic at the right dose, at the right time, and for the right duration in all settings. For details, please refer to the (NICE 2015, PHE, BSAC, and IDSA) guidelines on the practical implementation of an antibiotic stewardship programme.

In summary, the following strategies should be used in healthcare settings to promote the appropriate use of antimicrobial agents:

  • Educate clinical staff on the appropriateness of prescribing.
  • The most up-to-date guidelines should be readily available in the wards and clinical areas, and access should be available in the hospital on the intranet and handheld devices.
  • Prescribe antibiotics for good clinical reasons, with clear documentation of the reason for prescribing in the medical notes.
  • Prescribe narrow-spectrum antibiotics, where possible, with a minimum recommended duration.
  • If the antibiotic is prescribed as empirical therapy, it must be reviewed within 48 hours. Based on the clinical diagnosis, the following should be noted: intending to stop, continue, change, or switch from IV to oral therapy.
  • If antibiotic therapy is needed, change to a narrow-spectrum antibiotic once the bacteriology results are available.
  • Microbiology laboratories should introduce restricted reporting to encourage the use of narrow-spectrum antibiotics, which are part of the local antibiotic formulary.
  • Restrict prescription of critical antibiotics, especially carbapenems (meropenem, ertapenem, imipenem, and doripenem), glycopeptides (vancomycin, teicoplanin, dalbavancin, and telavancin), lipopeptides (e.g. daptomycin), and Linezolid.
  • Topical mupirocin should be restricted for the decolonisation of MRSA only.

WHO has classified antibiotics into four groups: Access, Watch, Reserve (AWaRe), and a fourth group, Not Recommended. More than 200 other antibiotics have now been classified into AWaRe groups to help inform local and national policy development and implementation.

The following criteria were used to select antibiotics for Access antibiotics:

  • Narrow spectrum of activity
  • Lower cost
  • Good safety profile and generally
  • Low resistance potential.

These antibiotics are often recommended as empiric first or second-choice treatment options for common infections.

Watch antibiotics are broader-spectrum antibiotics, generally with higher costs, and are recommended only as first-choice options for patients with more severe clinical presentations or for infections where the causative microorganisms are more likely to be resistant to the Access group of antibiotics. It is essential to note that the Reserve antibiotics are the last choice for treating multidrug-resistant infections.

To promote responsible use of antibiotics and slow the spread of antibiotic resistance, the WHO Global Programme of Work includes a target that at least 60% of total antibiotic prescribing at the country level should be Access antibiotics by 2023.

In a healthcare setting (especially in the community), most otherwise healthy patients with mild common infections can be treated without antibiotics. These infections are frequently self-limiting, and the potential antibiotic-related side effects outweigh the clinical benefits. These include allergic reactions, selection of resistant bacteria, and Clostridioides difficile infection. Patients treated with symptomatic care only (no antibiotic care) must be informed of what danger signs to monitor and what to do if they occur.


·      Diagnose: What is the clinical diagnosis? Is there evidence of a significant bacterial infection?

·      Decide: Are antibiotics really needed? Do I need to take any microbiology cultures or other tests?

·      Drug (medicine):  Which antibiotic to prescribe? Is it an Access or Watch or Reserve antibiotic? Are there any allergies, interactions or other contraindications?

·      Dose: What dose, how many times a day? Are any dose adjustments needed, for example, because of renal impairment?

·      Delivery: What formulation to use? Is this a good quality product? If intravenous treatment is needed, when is step down to oral delivery possible?

·      Duration: For how long? What is the stop date?

·      Discuss: Inform the patient of the diagnosis, likely duration of symptoms, any likely medicine toxicity and what to do if not recovering.

·      Document: Write down all decisions and the management plan.

Source: The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022.

LINK to Primary Care Antibiotic Prescribing Guidelines

Key references and further reading

  • Antimicrobial stewardship Quality standard. London: The National Institute for Health and Care Excellence. 22 April 2016.

  • Antimicrobial Stewardship: Systems and Processes for Effective Antimicrobial Medicine Use (NG 15). London: The National Institute for Health and Care Excellence. 18 August 2015.

  • Start Smart–Then Focus Antimicrobial Stewardship Toolkit for English Hospitals. London: Public Health England. 2023.

  • BSAC Antimicrobial Stewardship: From principle to practice. Birmingham: British Society for Antimicrobial Chemotherapy.2018.

  • Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, Clinical Infectious Diseases, 2016: 10;e51–e77.

The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Geneva: World Health Organization; 2022.