💊 General Strategies to Reduce Antimicrobial Resistance in Clinical Practice

1. IV to Oral Switch (IVOS)

One of the most effective and safe interventions in antimicrobial stewardship.

🔁 Why switch from IV to oral early?

• Reduces complications (e.g. line infections, thrombosis)

• Lowers costs and bed-days

• Improves patient comfort and mobility

• Oral options (e.g. ciprofloxacin, fluconazole, linezolid) are highly bioavailable, often matching IV efficacy

✅ When is IVOS appropriate?

• Clinical improvement seen

• Source controlled

• Oral route available and tolerated

• Suitable oral alternative exists

NHS guidance: “Start smart – then focus” encourages early IVOS reviews within 48–72 hours of antibiotic initiation.

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2. “Start Smart – Then Focus” (UK NHS Framework)

This key NHS antimicrobial policy includes:

• Start Smart: Prescribe antibiotics appropriately from the beginning

• Then Focus:

  • Review at 48–72 hours

  • Consider stop, switch, change, or continue

  • Document clearly in records

Supported by NICE guidelines and UKHSA audits

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3. Shorter Duration of Therapy

For many infections, shorter courses (e.g. 5–7 days instead of 10–14) are now preferred.

Examples:

• Community-acquired pneumonia: 5 days

• Pyelonephritis: 7 days

• Cellulitis: 5–7 days

This reduces resistance pressure and side effects.

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4. Diagnostics-Guided Prescribing

• Procalcitonin and CRP tests can help distinguish bacterial from viral infections

• Rapid PCR, MRSA, or blood culture diagnostics guide targeted therapy

The aim is avoid empirical broad-spectrum antibiotics where possible.

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5. Restricted Prescribing Policies

• Certain high-risk drugs (e.g. carbapenems, vancomycin, antifungals) are restricted to ID approval

• Antimicrobials are tiered by risk (e.g. traffic light systems) to encourage narrow-spectrum use

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6. Antimicrobial Stewardship Teams (ASTs)

Multidisciplinary teams:

• Lead on stewardship strategy

• Audit antimicrobial use

• Provide decision support for complex cases

• Educate staff and update local formularies

In the NHS, stewardship is a CQUIN target (incentivised performance indicator).

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7. Education and Behaviour Change

• Mandatory AMS training for junior doctors and prescribers

• Behavioural nudges in electronic prescribing systems (e.g. default shorter durations, alert for IVOS)

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8. Surveillance and Reporting

• ePAMS+, ESPAUR, and PHE Fingertips dashboards track:

  • Prescribing by hospital/unit

  • Resistance trends

  • Audit compliance with IVOS, duration, and documentation

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9. Patient-Facing Initiatives

• “Antibiotic Guardian” and leaflets explaining viral vs bacterial infections

• Empowering patients to ask:

  “Do I really need antibiotics? When can I switch to tablets?”

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📦 Summary Table: Key Interventions

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