Anti microbial stewardship ✅

🦠 Antimicrobial stewardship means using antibiotics, antivirals, antifungals and antiparasitic medicines carefully so that patients get effective treatment while reducing avoidable harm and antimicrobial resistance. NICE defines antimicrobial stewardship as a healthcare-system-wide approach to promoting and monitoring judicious antimicrobial use to preserve future effectiveness.

Antimicrobial stewardship 🦠

Antimicrobial stewardship is the safe, targeted and responsible use of antimicrobial medicines. The aim is to treat true infection effectively, avoid unnecessary prescribing, reduce side effects, prevent Clostridioides difficile, and slow antimicrobial resistance.

Why it matters 🚨

• Resistance: unnecessary antibiotic use selects resistant organisms.
• Patient harm: antibiotics can cause allergy, renal injury, liver injury, diarrhoea and drug interactions.
• C. difficile: broad-spectrum antibiotics increase the risk of antibiotic-associated colitis.
• Diagnostic clarity: antibiotics before cultures can make later microbiology harder to interpret.
• Public health: antimicrobial resistance reduces future treatment options for everyone.

Core principle 🎯

Use the right antimicrobial, for the right patient, at the right dose, by the right route, for the right duration. Do not prescribe antibiotics for viral illness, colonisation, contamination, or non-infective inflammation.

Before prescribing antibiotics 🧠

• Is there likely bacterial infection?
• What is the suspected source?
• Is the patient septic or clinically unstable?
• Are cultures needed before treatment?
• What organisms are likely?
• What is local resistance like?
• Does the patient have allergy, renal impairment, pregnancy, liver disease or immunosuppression?
• Can narrow-spectrum treatment be used?

Start smart, then focus ⏱️

In severe infection or sepsis, give antibiotics promptly after appropriate cultures where this does not delay urgent treatment. Once results and clinical response are available, review therapy and narrow, stop, switch or continue with a documented plan.

• Start smart: treat promptly when bacterial infection is likely or the patient is seriously unwell.
• Then focus: review at 24–72 hours using clinical progress and microbiology.
• Document: indication, drug, dose, route, duration and review date.

Antibiotic review at 48–72 hours 🔍

• Stop: if infection is unlikely.
• Switch: IV to oral if improving and able to absorb.
• Narrow: change broad-spectrum treatment to targeted therapy.
• Continue: if still indicated, with a clear duration.
• Escalate: if deteriorating, resistant organism suspected, or source control needed.

Common stewardship actions ✅

• Take blood cultures before antibiotics in sepsis where this does not delay treatment.
• Send urine, sputum, wound, stool or CSF samples only when clinically indicated.
• Avoid treating asymptomatic bacteriuria except in selected groups such as pregnancy or before some urological procedures.
• Use narrow-spectrum antibiotics where possible.
• Review IV antibiotics daily.
• Switch to oral antibiotics when clinically appropriate.
• Use the shortest effective course recommended by local or national guidance.
• Seek microbiology advice for severe, recurrent, resistant or complex infections.

Medication examples 💊

When broad-spectrum antibiotics are appropriate 🚑

• Sepsis or septic shock.
• Neutropenic sepsis.
• Meningitis or encephalitis.
• Severe hospital-acquired infection.
• Known resistant organism or previous resistant colonisation.
• Immunocompromised patient with serious infection.
• Deep infection requiring urgent treatment while awaiting cultures.

When antibiotics may not be needed 🚫

• Viral upper respiratory tract infection.
• Most acute bronchitis in otherwise well patients.
• Asymptomatic bacteriuria in most non-pregnant adults.
• Colonised chronic wounds without spreading infection.
• Positive swab from a wound with no clinical infection.
• Raised CRP alone without clinical evidence of bacterial infection.
• Fever from non-infective causes such as PE, drug fever, autoimmune disease or malignancy.

IV-to-oral switch 💉➡️💊

Consider switching from IV to oral antibiotics when the patient is clinically improving, haemodynamically stable, able to absorb oral medication, and there is a suitable oral option.

• Afebrile or improving temperature trend.
• Improving inflammatory markers and symptoms.
• No vomiting, ileus or absorption problem.
• No infection requiring prolonged IV therapy, such as endocarditis or some CNS infections.
• Clear oral antibiotic choice and duration documented.

Source control 🔧

Antibiotics alone may fail if the source is not controlled. Drain abscesses, remove infected lines, debride necrotic tissue, relieve obstruction and obtain surgical or radiological input when needed.

Common exam and ward pitfalls ❌

• Prescribing antibiotics for “just in case” without a suspected source.
• Not documenting indication or stop/review date.
• Forgetting cultures before antibiotics in sepsis.
• Continuing broad-spectrum IV antibiotics when the patient is improving.
• Treating colonisation rather than infection.
• Ignoring renal dose adjustment.
• Missing source control.
• Not checking allergy history properly.

Makindo exam summary 🎯

For exams, antimicrobial stewardship means: confirm infection, identify the likely source, take cultures when appropriate, start prompt treatment if seriously unwell, then review at 48–72 hours to stop, narrow, switch or continue. The best answer is usually not “give the strongest antibiotic”, but “give the most appropriate antibiotic and review it early.”

References 📚

• NICE. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. NICE guideline NG15. Published 18 August 2015.
• NICE. Antimicrobial stewardship: changing risk-related behaviours in the general population. NICE guideline NG63. Published 25 January 2017.
• UK Health Security Agency. Start smart then focus: antimicrobial stewardship toolkit for inpatient care settings.

Disclaimer 📚

This article is for medical education and revision only. Antimicrobial prescribing should follow local antimicrobial guidelines, microbiology advice, allergy history, renal and hepatic function, pregnancy status, drug interactions, severity of illness and current national guidance.