From digital prescribing tools to culture change and education, the realm of antimicrobial stewardship is vast and clinicians across the UK and Europe have a vital role in progressing it, with support from colleagues in pharmacy, as Saša Janković explains.

Antimicrobial resistance (AMR) is a serious global problem, and concerns over its impact on the health of UK, European and global populations are never far from the headlines.

A study published by the UK Health Security Agency (UKHSA) in April showed some bacteria have already become resistant to one of the newest antibiotics. Analysing data from 2016 to 2020, the study found that 6.3% of bacteria tested in routine surveillance showed resistance to ceftazidime/avibactam – an antibiotic used in the NHS since 2017 to treat some of the most serious infections in hospitals.

That same month, a study presented at the Congress of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in Vienna revealed that over three million children worldwide died from AMR-related infections in 2022. The study highlighted a sharp increase in the use of Watch and Reserve antibiotics – drugs with a high risk of driving resistance and typically reserved for severe or multidrug-resistant infections – raising concerns about dwindling treatment options. It also echoed the need for the World Health Organization (WHO)’s One Health approach that links human, animal and environmental health.

On a more hopeful note, earlier in August, researchers from the Massachusetts Institute of Technology announced the successful development of two de novo antibiotics using generative artificial intelligence (AI) algorithms. These have been shown to combat drug-resistant Neisseria gonorrhoeae and multi-drug-resistant Staphylococcus aureus (MRSA).

Lead author Aarti Krishnan said: ‘We wanted to get rid of anything that would look like an existing antibiotic, to help address the antimicrobial resistance crisis in a fundamentally different way. By venturing into underexplored areas of chemical space, our goal was to uncover novel mechanisms of action.’

Global AMS guidelines

The potential use of these novel antibiotics in clinical practice is some way off and there are immediate actions that healthcare professionals and policymakers can take to support antimicrobial stewardship (AMS).

As patterns of AMR vary considerably around the globe, the WHO says every country should have a national action plan on AMR to include avoiding overuse and misuse of antibiotics.

At the 79th United Nations General Assembly’s High-Level Meeting on AMR in 2024, countries committed to ensuring that at least 70% of antibiotics used for human health are from the WHO Access Group Antibiotics, which have relatively minimal side effects and a lower potential to cause AMR.

ESCMID published guidelines for antimicrobial stewardship in emergency departments at the end of last year. These stress the need to adapt strategies to local emergency department contexts and prioritise multidisciplinary collaboration, as well as highlighting critical gaps in high-quality research, and urging further studies to strengthen stewardship practices in emergency care.

NHS England digital framework

In the UK, NHS England published its plans to tackle AMR through antimicrobial stewardship in April. Two documents outline the digital vision and digital framework required to leverage integrated digital infrastructure and optimise prescribing, enhance surveillance and support clinical decision-making.

This includes the universal adoption of electronic prescribing and medicines administration (ePMA) systems across hospitals, full interoperability with primary care through shared electronic health records and standardised diagnosis coding using the structured clinical vocabulary SNOMED CT within these.

This digital ecosystem underpins clinical decision support tools, educational feedback loops and benchmarks that empower prescribers to make informed antibiotic choices, while enabling robust infection surveillance and stewardship across the health and care system.

But using IT systems in the management of AMS is only part of the solution, with many healthcare settings spearheading examples of best practice and a coordinated approach across AMS teams.

A team approach to AMS

The AMS team at Royal Papworth Hospital NHS Foundation Trust received regional recognition for its outstanding success in exceeding two key Department of Health and Social Care and NHS England targets to support safer patient care: reducing use of critical watch and reserve antibiotics by 21% and ensuring 80% of intravenous antimicrobial prescriptions were appropriate for oral switch.

Elisha Zafar is a specialist infection pharmacist at Princess Royal University Hospital, which is part of King’s College Hospital NHS Foundation Trust in London, and is involved in the Trust’s efforts to champion AMS. This includes reducing inappropriate IV antibiotic usage across hospital sites to improve patient flow, reducing line associated infections, and increasing nursing capacity and earlier hospital discharges.

‘While this was initially driven by national healthcare goals, like NHS England’s CQUIN targets, we’ve continued the work to provide targeted IV to oral ward rounds with an infection multidisciplinary team (MDT) to help further push inappropriate IV antibiotic usage down,’ Elisha explains.

‘To further support this, we provide teaching to help clinicians, nurses and pharmacists feel more confident challenging prolonged IV use and making the switch. We also have a focus on penicillin allergy delabelling and distribute monthly infection newsletters sharing key updates relating to AMS, as well as ensuring the availability of up-to-date antimicrobial guidelines.’

In addition, the Trust has recently established a pharmacist-led Complex Outpatient Antimicrobial Therapy (COPAT) service. ‘This allows patients on long-term, particularly high-risk antibiotics to continue their treatment at home with appropriate monitoring and support in place to ensure safety and efficacy, which further promotes AMS but, more widely, supports patients in getting home sooner and less risk of developing hospital-associated infections,’ says Elisha.

At East Kent Hospitals University NHS Foundation Trust, Dr Veronica Chorro-Mari, consultant pharmacist antimicrobial stewardship, says AMS is a ‘central part’ of clinical pharmacy practice.

‘Pharmacists are in a unique position to influence prescribing, drive education, and ensure safe, effective antimicrobial use across the MDT,’ she says. ‘We take a strategic, data-driven approach and align our work with national strategies such as the UK’s Confronting Antimicrobial Resistance 2024 to 2029 plan,’ she says.

‘We perform daily prescription reviews, provide feedback and monitor key performance indicators – developed through MDT consensus – to track infection risk and adherence to thresholds, and maintain a formulary with pre-authorisation requirements for restricted antibiotics and actively participate in microbiology culture and sensitivity reviews, Dr Chorro-Mari adds.’

But she also emphasises: ‘AMS isn’t only about data and protocols; it’s about culture change. AMS is embedded into everything we do, and this year we are focusing on now prioritising education with short, frequent case discussions tailored to integrate AMS into daily pharmacy practice.’

Top AMS tips

Professor Mark Gilchrist is a consultant pharmacist in infectious diseases and AMS and leads the AMS programme at London’s Imperial College Healthcare NHS Trust. He says there are many ways in which the AMS team can work together to pursue best practice.

‘Promote the prudent use of antimicrobials – right antimicrobial, right patient, right dose, right duration – based on best available evidence and optimise pharmacokinetic and pharmacodynamic properties of the antimicrobial choice as best you can, based on information available,’ he says. He also advocates for ‘re-enforcing intravenous to oral switch opportunities and maximising the clinical, sustainability and resource opportunities’.

Professor Diane Ashiru-Oredope, deputy chief scientist at the Royal Pharmaceutical Society (RPS), agrees that the MDT is crucial to AMS and that pharmacists should be central to leading this.

‘Collaborating with prescribers to challenge inappropriate use of antimicrobials and reinforce adherence to evidence-based guidelines is essential to improving patient outcomes,’ she says, adding that effective stewardship also relies on educating and empowering staff and patients.

‘Hospital pharmacy teams should lead ongoing AMR awareness by training staff; supporting AMS champions on wards; joining multidisciplinary education sessions, ward rounds or quality improvement initiatives; and promoting public health messages such as “Antibiotics aren’t always the answer” to patients and carers,’ Professor Ashiru-Oredope adds.

However, she acknowledges a range of factors that complicate this. ‘Prescribing is often influenced by clinician anxiety, time pressures and patient expectations rather than clinical need, and changing this requires long-term investment in education, behavioural science, and system-wide culture change,’ she says.

Challenges and opportunities

One of the most pressing concerns anticipated in the future of AMR is the lack of new antimicrobials – newly AI-designed examples aside – due to a limited pipeline and few incentives for the pharmaceutical industry. ‘Cost is a parameter impacting hospital pharmacists and we also rely on older agents and combination of therapies to treat resistant infections, which makes optimising prescribing practices more important than ever,’ says Dr Chorro-Mari.

‘Genomics will also help future diagnostics and treatment plans,’ says Dr Louise Dunsmure, consultant pharmacist – antimicrobial stewardship at Oxford University Hospitals NHS Foundation Trust, and chair of the RPS Antimicrobial Expert Advisory Group. ‘The UK’s digital vision offers potential for optimising prescribing [and the] subscription model is helpful, but stock shortages still risk suboptimal treatment. We also need to improve how we help patients and carers understand their medicines and infections.’ One way to achieve this, she says, is using technology to build on existing campaigns.

Thankfully, there may be some light at the end of the tunnel. For example, researchers at Brunel University have discovered that the artificial sweetener saccharin can disrupt bacterial cell walls, interfere with DNA replication, prevent biofilm formation and even make resistant strains more susceptible to existing antibiotics.

At the University of Manchester, scientists are exploring the use of friendly bacteria that deploy their own molecular syringes to inject toxins directly into harmful pathogens. Meanwhile, hospital pharmacists and clinical teams are using bacteriophages to precisely target and kill multidrug-resistant infections, with increasingly promising results.

And it’s a sustained MDT approach that will continue to be essential, according to Professor Ashiru-Oredope, who advocates for ‘a coordinated One Health approach’. But she cautions that as ‘implementation remains fragmented across much of the world’, tackling AMR ‘requires both improving access where needed and promoting responsible use everywhere’.