Antimicrobial Stewardship
A multidisciplinary framework to optimise antimicrobial use, improve outcomes, reduce adverse effects, and contain resistance. UK hospitals use stewardship teams, formulary restrictions, and audit with feedback aligned to NICE and UKHSA principles.
Key Facts
Key points
- Start smart: right drug, dose, route, and narrowest effective spectrum as soon as cultures allow.
- Document: indication, planned review/stop date (often 48–72 hours) on drug charts.
- IV to oral switch when swallowing safe and clinically improving (e.g. co-amoxiclav 625 mg TDS**).
- Peri-operative prophylaxis: typically single dose cefazolin 1–2 g IV** or co-amoxiclav 1.2 g IV** at induction for clean-contaminated surgery — repeat only if prolonged bleeding or short half-life drug — per local protocol.
- C. difficile risk: minimise cephalosporins/quinolones/clindamycin when alternatives exist.
- Antibiotic allergy: clarify true IgE-mediated allergy vs intolerance; delabelling programmes improve beta-lactam access.
Overview
Core interventions
Formulary, pre-authorisation for restricted agents, prospective audit, education, and IT decision support.
Metrics
Consumption (DDD/1000 OBD), C. difficile rates, resistance trends.
Clinical Presentation
Stewardship "presentation"
Not a disease — applies to every prescribing episode: sepsis, UTI, pneumonia, skin infection.
Differential Diagnosis
Misuse patterns to recognise
- Treating asymptomatic bacteriuria.
- Continuation beyond guideline duration without indication.
- Broad-spectrum cover "just in case" without review.
Diagnosis / Investigation
Stewardship review checklist
- Cultures, biomarkers (PCT where used), source control achieved?, drug levels (vancomycin, gentamicin).
Management
Practical steps (ward level)
- De-escalate after sensitivities.
- Stop duplicate cover unless clear reason.
- Dose adjust for renal function (gentamicin extended interval; vancomycin AUC-guided where available).
Restricted antibiotics
Meropenem, linezolid, daptomycin — discuss with microbiology for appropriateness and duration.
Prognosis
Effective stewardship reduces resistant infections and hospital-acquired C. difficile over time.
Other Relevant Information
Primary care
Delayed/back-up prescriptions for minor RTIs; FeverPAIN/CENTOR criteria reduce unnecessary antibiotics.