Reducing healthcare-associated infections and antimicrobial resistance requires more than health systems knowing what works – they need to know how to make it work. Here, Gerry Hughes reports from ESCMID Global 2026, where there was a particular focus on how implementation science can guide and augment the impact of infection prevention and control and antimicrobial stewardship across complex clinical systems.

Infection prevention and control (IPC) and antimicrobial stewardship (AMS) are grounded in strong evidence, but their success in hospitals depends on how reliably evidence is implemented in routine care.

At ESCMID Global 2026, speakers explored how implementation science can help hospitals understand why evidence succeeds in some settings and stalls in others, by examining the interaction between behaviour, relationships, organisational context and clinical practice.

Discussions linked guidance and surveillance to the everyday work of change: how teams communicate, how prescribers make decisions, how hierarchy shapes uptake, how data supports review and how trust is built.

Such changes in practice require a scientific approach that defines the target behaviour, identifies barriers, initiates the selection of strategies that match those barriers and then monitors progress and adapts over time.

REVERSE and the science of making IPC and AMS work

The pREVention and management tools for rEducing antibiotic Resistance in high prevalence SEttings (REVERSE) project provided the main case for this implementation-focused approach.

This Horizon 2020-funded stepped-wedge, hybrid type 2 effectiveness–implementation cluster randomised trial involved 24 acute care hospitals in Greece, Italy, Romania and Spain. Participating hospitals were selected because of high levels of multidrug-resistant organisms (MDROs) and healthcare-associated infections.

The trial examined the sequential implementation of IPC and AMS bundles and the impact of applying a structured implementation science approach in routine hospital practice.

Walter Zingg, professor of infectious diseases at University Hospital Zurich, Switzerland, is part of the REVERSE study group and co-chaired an ESCMID GLobal 2026 session focused on enhancing IPC through implementation science.

In direct terms, Professor Zingg described the rationale for this study: ‘REVERSE throws everything at the problem, and “everything” is diagnostic stewardship, infection prevention and AMS.’

He further explained that transmission and infection with MDROs in hospitals, alongside antimicrobial use, are two of the main drivers of antimicrobial resistance (AMR). For this reason, IPC and AMS ‘belong together’, he said.

This combined approach also brings complexity because diagnostic pathways, infection prevention practices and prescribing behaviours sit across different professional groups, workflows and decision-making structures.

Shifting from ‘what works’ to ‘how to make it work’

During her ESCMID Global talk, Kathrin Blum, a psychologist and PhD student at the University of Zurich’s Institute for Implementation Science in Health Care, framed implementation science as the discipline that asks how evidence can be made to work in real settings. She described a shift from asking ‘what works?’ to ‘how to make it work?’.

A key concept is the level of readiness that hospital and health systems have for implementation of complex interventions such as IPC and AMS.

Her research found that successful IPC implementation depended on the complexity of the intervention and the local conditions supporting it. For complex IPC changes requiring major behaviour change, cross-professional collaboration, data infrastructure, environmental changes or additional resources, hospitals were more likely to start promptly when organisational readiness for change was high.

This included staff confidence, shared commitment, leadership support and clear implementation plans. For less complex interventions, timely implementation depended more on matching local barriers with appropriate strategies.

The practical message for hospitals was to assess intervention complexity early, then decide whether to prioritise readiness-building or focused barrier-strategy planning.

Tools for IPC and AMS implementation in hospital practice

REVERSE uses a series of implementation science tools to examine whether hospitals are ready for change, considering whether implementation started well, if leadership supported the work and whether strategies matched local barriers.

These tools also offer a practical template for hospital teams planning IPC or AMS improvement work:

Culture, hierarchy and boundary-spanning

Dr Diana Gabriela Iacob, a researcher at Bucharest University Emergency Hospital, Romania, used her ESCMID Global session to describe organisational culture as a key determinant of IPC implementation.

At her hospital, a cultural comparison instrument was used to examine indices such as power distance, motivation towards achievement and success, and uncertainty avoidance, as potential barriers for change.

Results from this analysis showed that hierarchy needed to be considered in IPC implementation. In response, clinicians in senior or influential positions were selected as role models to support uptake.

‘REVERSE really did make a change, and it started to increase our disinfectant consumption. Had it not been for REVERSE, it would have gone down,’ she hypothesised. ‘Hand hygiene compliance rates have also increased, from 29% to 40% compliance.’

Dr María Teresa Pérez-Rodríguez, infectious diseases specialist at Álvaro Cunqueiro Hospital, University Hospital of Vigo, Spain, focused her ESCMID Global session on boundary spanning as a prerequisite for IPC implementation. She said this was needed to coordinate independent teams in an interdepartmental and multidisciplinary hospital setting.

At her large public hospital, which spans three buildings and approximately 1,200 inpatient beds, baseline hand hygiene compliance was low at 24%.

Coordination between departments was limited, and it was noted that Spain’s position as the only European country where infectious diseases is not a medical speciality added another layer of complexity.

‘At the beginning we had two teams working on hand hygiene,’ she said. ‘One was a nurse-led quality department. The other was an IPC team led by epidemiologists and preventionists. They were working on separate projects with limited alignment.’

For Dr Pérez-Rodríguez, REVERSE created a route to joint working as she ‘realised it was an opportunity to change the situation in my hospital’.

She identified roadblocks to collaboration, which included fragmented organisational silos, entrenched power disparities and fixed mental models.

The response was to create shared ownership and a common identity around hand hygiene. As a result, hand hygiene compliance reached 40% and the hospital observed a decrease in MDRO infections.

Leadership, data and antimicrobial prescribing behaviour

The AMS dimension was illustrated by Dr Davide Mangioni, a consultant in infectious diseases at Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico – an urban tertiary referral centre in Milan.

Before 2023, it had no antimicrobial consumption surveillance and no prescription control policy for reserved antimicrobial agents.

‘Everybody could prescribe carbapenems, fosfomycin and intravenous colistin,’ Dr Mangioni explained during his ESCMID Global session, adding that the team had a sense that these drugs were being overprescribed but lacked the required reporting systems to measure the scale of the problem.

The hospital therefore built an antimicrobial prescribing monitoring system and introduced restrictions for priority antimicrobials. These restrictions acted as decision points in the prescribing pathway, prompting clinicians to reconsider the need for reserve agents such as meropenem.

Daily and weekly assessments of priority antimicrobials by the infectious diseases service were supported by automatic extraction of patient data.

Dr Mangioni stressed that the work depended on relationship building across the hospital. ‘It’s not just infectious diseases, it’s teamwork,’ he said, highlighting an important communication triangle between microbiology, attending physicians and the infectious diseases service, which came to be seen as a partner rather than an external controller.

He also emphasised that the leadership approach depended on trust built with hospital staff over months and years.

Following restrictive prescribing interventions and proactive antimicrobial therapy assessments, carbapenem prescribing fell by more than 50%.

AMS from different perspectives

Further data presented at ESCMID Global 2026 reinforced the importance of a holistic approach to AMS.

A multi-centre Italian study (ESCMID Global 2026 poster E0039) informed by the Capability, Opportunity, Motivation Behaviour model and the Theoretical Domains Framework, surveyed 258 physicians across six hospitals. The target behaviour was prescribing antibiotics according to guidelines.

Overall, 72% reported often adhering to national or international guidelines, 61% agreed that diagnostic results were available in time to support targeted prescribing, and 95% believed guideline-adherent prescribing contributed to AMR control.

The findings showed behavioural variation across specialities. Surgical areas had lower confidence of AMS impact and greater knowledge gaps, highlighting a need for increased education alongside timely diagnostics, decision support and optimised workflow design.

A further study described a restructuring of the AMS strategy at an NHS trust (ESCMID Global 2026 poster E0236). Behaviour-change principles including prescriber commitment, audit and feedback, decision support and peer comparison were deployed.

A series of AMS-focused activities were developed prospectively through regular multidisciplinary meetings involving pharmacists, nurses, microbiologists and clinicians.

This led to a decrease in broad-spectrum antibiotic consumption by 3% over two years, stabilising a previously rising trend. The work also positioned pharmacy-led AMS teams as key drivers of change.

Patient understanding and education around AMS

Patient-facing AMS data presented at ESCMID Global 2026 showed that stewardship also depends on how patients understand, question and participate in antibiotic decisions.

A mixed methods study (ESCMID Global 2026 poster E0032) surveyed 360 hospitalised patients across six disease groups. Among respondents, 68% were receiving antibiotics while completing the survey, and while 64% of the respondents had heard of AMR, 93% had never heard the term ‘antimicrobial stewardship’.

Education was the strongest predictor of AMR and AMS knowledge, but knowledge did not translate directly into confidence or willingness to challenge prescribing decisions. Patients were more comfortable asking basic treatment-related questions than challenging antibiotic prescribing.

The study authors recommended that hospital AMS programmes should build patient engagement into routine practice, using approaches tailored to clinical specialty, education level and patients’ information needs to support more informed involvement in infection treatment decisions.

A systematic review and meta-analysis (ESCMID Global 2026 poster E0038) brought the patient and public picture into sharper focus. Across 27 studies, only 45% of participants had adequate AMR knowledge and reported appropriate antimicrobial use practices, while 44% demonstrated positive attitudes.

High heterogeneity across studies and marked global variation pointed to the influence of local context on AMR knowledge and behaviours. The authors concluded that strengthening patient and public understanding is central to advancing effective AMS.

Extending behaviour change beyond the bedside

Professor Raheelah Ahmad, professor of health systems at City St George’s, University London, gave a session on implementing infection control best practices across diverse resource settings, widening the focus from clinician and patient behaviour to public engagement.

She highlighted the Fleming Initiative – a new partnership between Imperial College and Imperial College NHS Trust, for which she is research strategy advisor (health systems & policy) and co-lead of the informed policy pillar.

Another of its core pillars is public engagement and behaviour change, which Professor Ahmad said is built around a clear proposition: ‘If we change our behaviours, we can keep antibiotics working for another hundred years.’

The Fleming Initiative aims to identify priorities for behaviour change, explore behavioural determinants and work with the public to co-create interventions that support collective action on AMR.

Professor Ahmad also discussed emerging evidence that AMR education for children and adolescents remains largely knowledge-focused, weakly scaled and rarely evaluated for behaviour change or downstream impact on antimicrobial use, infection rates or resistance rates.

Citing seasonal influenza vaccine uptake in frontline healthcare workers, she also described how the data illustrate a similar implementation gap. For the six months from September 2025 to February 2026 46% of frontline healthcare workers in England had received influenza vaccination, including 46% in NHS trusts and 56% in GP practices.

Across Europe, influenza vaccine coverage rates for healthcare workers range from 17% to 63%, with a median of 32%. These figures show how far recommendations can sit from routine uptake, even for familiar infection prevention measures.

Conclusion

IPC and AMS depend on protocols, data and specialist expertise, but they also depend on people – their habits, confidence, pressures, relationships and willingness to change.

As explored at ESCMID Global 2026, implementation science gives structure to that human work. It guides hospitals to look closely at the context before asking for new behaviours, to build trust before expecting adherence and to match interventions to the barriers staff and patients actually face.

In a field where small failures can have large consequences, making the evidence work in daily practice may be one of the most important infection prevention tools available.