Purpose and audience

The best practice guidance is designed for implementation by directors of infection prevention and control and antimicrobial stewardship teams in acute hospital trusts and is also intended as a reference source for integrated care board (ICB) commissioners and NHS England and the Department of health and Social Care (DHSC) regional teams.

Context

Antimicrobial resistance (AMR) presents an escalating threat to public health in the UK and globally and a barrier to meeting the national priorities to reduce the time people wait for elective care and improve A&E waiting times. Broad-spectrum antibiotics – classified by the WHO as Watch and Reserve agents – are key contributors to antimicrobial resistance when misused or overused. To address this, the NHS Standard Contract required acute trusts to reduce Watch and Reserve antibiotic consumption by 10% from 2017 levels by 2023/24, in line with the UK’s 5-year National Action Plan on AMR (2019–2024).

Of 132 NHS trusts with reported data, only 23% met the 10% reduction target, while 57% increased consumption. To understand this variation, NHS England conducted 24 interviews with antimicrobial stewardship leads from trusts with the largest relative increases and decreases in consumption from each of the seven regions (7 trusts that increased and 8 trusts that reduced their Watch and Reserve antibiotic consumption). These interviews explored key enablers, barriers, and strategies for antimicrobial stewardship (AMS). Interviewees were in a variety of roles: pharmacy antimicrobial stewardship lead (n=14), microbiologist (4), chair of antimicrobial stewardship committee (7), director for infection prevention and control (3), medical director (2), antimicrobial stewardship nurse (1), pharmacy leadership (3).

The findings below demonstrate that sustained reductions in broad-spectrum antibiotic use are achievable when stewardship is prioritised, resourced, and embedded in acute hospital trusts. A number of practical real-world examples of Watch and Reserve antibiotic reduction strategies were reported and can be adapted for use by trusts.

Main findings

1. Performance can be improved irrespective of baseline antibiotic consumption

Data on Watch and Reserve antibiotic consumption reported for 132 of 135 acute and specialist trusts in England and differences between 2017 and 2023-2024 (the final year of the 2019–2024 National Action Plan on AMR) were analysed. Two trusts lacked 2023-2024 data due to new IT systems, and one was excluded for data quality issues.

There was considerable variation in performance at the individual trust level, with relative changes ranging from a 36% reduction to a 66% increase in Watch and Reserve defined daily doses per 1000 admissions. Notably, baseline consumption did not predict improvement, as trusts with low initial use still achieved further reductions:

• 30 trusts with largest reductions – baseline Watch and Reserve antibiotic consumption ranged from 1,018 to 7,589 DDDs per 1000 admissions
• 30 trusts with largest increases – baseline Watch and Reserve antibiotic consumption ranged from 893 to 4,891 DDDs per 1000 admissions

2. Trusts that successfully reduced their antibiotic consumption reported multiple facilitative antimicrobial stewardship strategies

Interviewees from trusts that successfully reduced Watch and Reserve antibiotic use reported more facilitators across all areas and had a clearer understanding of how antimicrobial stewardship activities affected consumption. In contrast, those from trusts without improvement were less certain about these factors and identified more barriers.

Similarly, trusts that reduced Watch and Reserve consumption were more likely than those with an increased consumption to have a written antimicrobial stewardship strategy (79% versus 50%) and to report that it was used to drive improvement efforts (43% versus 20%). They were also more likely to have a formal antimicrobial stewardship workplan in place (79% versus 30%).

3. Updating and using guidelines to facilitate behaviour change was the most commonly used strategy

Respondents from trusts that successfully reduced Watch and Reserve antibiotic consumption frequently identified changes to empirical treatment guidelines as key facilitators. Specifically, 93% highlighted updates to first-line antibiotic choices (to prioritise Access antibiotics), and 71% revised recommended treatment durations. In contrast, only 30% and 40% of respondents from trusts with increased use reported these factors.

A major barrier was the lack of regular guideline review, particularly where existing guidance predominantly recommends Watch antibiotics.

Key themes from the interviews included the value of practical, regularly updated local guidelines, with examples such as:

• switching from Watch to Access antibiotics for first-line treatments:
  • using doxycycline and amoxicillin instead of co-amoxiclav and macrolides for community-acquired lower respiratory tract infections
  • replacing co-amoxiclav and quinolones with co-trimoxazole for hospital-acquired pneumonia, aspiration pneumonia, and infective exacerbations of chronic obstructive pulmonary disease
  • using gentamicin for Gram-negative infections (as a single agent or in combination to extend coverage)
• optimising treatment durations to reduce unnecessary exposure:
  • shortening courses where evidence supports it (for example, 5 days of treatment for respiratory infections, 7 days for Gram-negative bloodstream infections with urinary source, 10 days for infective exacerbations of cystic fibrosis)
  • intensifying initial treatment by using higher doses or a one-off administration of an aminoglycoside to enable shorter overall therapy
• supporting clinicians to use narrower spectrum antibiotics:
  • differentiating lower versus upper urinary tract infections
  • using local resistance data to guide choices (for example, low amoxicillin resistance in Strep. pneumoniae)
  • expanding local guideline coverage to more infections reduce reliance on broad-spectrum antibiotics when guidance is lacking
• Supporting use of Access antibiotics amid diagnostic uncertainty:
  • introducing dual-diagnosis sections guiding use of Access antibiotics (for example, when the differential diagnosis includes chest and urine infections)
  • removing antibiotic recommendations for undifferentiated sepsis from guidelines and providing education to support clinicians to identify the source of sepsis
• Improving guideline structure and review processes:
  • easy access via staff’s preferred platform(s). This was an online guideline using desktop computers (and no mobile apps) in some trusts and both mobile phone apps and desktop computers in others
  • embedding decision-support to guide treatment choices based on infection severity
  • providing detailed practical advice on how and when to step down therapy, when to use second- or third-line agents, diagnostic sampling, and when urgent microbiology input is required
  • including advice on 48–72 hour reviews, with stopping antibiotics as the default unless ongoing treatment is clearly needed (for example, aspiration pneumonia – stop at 3 days if no chest X-ray changes)implementing structured processes and updating small sections of guidance (rather than re-issue of an entire guideline) to enable rapid implementation of new evidence into practice
  • actively promoting updated guidance to support rapid adoption

4. Using a data-driven improvement approach was a key enabler for reducing Watch and Reserve antibiotic consumption

Trusts that reduced their Watch and Reserve antibiotic consumption effectively leveraged digital systems and surveillance data to support antimicrobial stewardship. Access to data and the skills to interpret it were key enablers reported by 79% and 50% of trusts that reduced their Watch and Reserve consumption, compared to just 30% and 10% of trusts who increased. However, lack of data analysis expertise remained a common barrier across both groups (40% of reducers; 43% of increasers).

Specific examples include the following to support quality improvement:

• track real-time consumption trends using Refine (Rxinfo®)
• benchmark against national data
• utilise automated electronic reports
• implement regular audit and feedback cycles
• incorporate surveillance data into guidelines
• use ICNet Hospital Suite to support quality improvement work and enable automated reporting of patient-level data

5. Antimicrobial stewardship workforce capacity was a strong differentiator

Workforce capacity and capability showed the most marked differences between organisations that reduced Watch and Reserve antibiotic use and those where it increased.

In all organisations, the antimicrobial stewardship lead role was held by a consultant microbiologist, an antimicrobial stewardship pharmacist, or both. However, there was substantial variation in the amount of time formally allocated to the role, ranging from no dedicated time to one whole-time equivalent (WTE). Notably, the 3 interviewees who reported having no dedicated time for the role were in organisations with increased Watch and Reserve consumption.

Antimicrobial stewardship team staffing levels also varied. Organisations that reduced Watch and Reserve antibiotics reported higher staffing (mean 2.70 WTE per 500 beds; range 0.17–8.06) compared to those with increased use (mean 1.68 WTE per 500 beds; range 0.25–6.02). Specific examples of under-resource from the latter organisations were:

• general understaffing in pharmacy
• lack of maternity-leave cover
• vacant antimicrobial stewardship pharmacist posts
• limited microbiology consultant time for antimicrobial stewardship
• suspension of antimicrobial stewardship activity due re-prioritisation of clinical activities

Among organisations that reduced Watch and Reserve use, some had increased antimicrobial stewardship staffing and capacity through:

• added hours
• new roles
• upgrades to existing posts
• involving ward staff in antimicrobial stewardship audits and quality improvement projects
• prioritising patient reviews over audits and report writing
• embedding antimicrobial stewardship in induction for all prescribers
• incorporating antimicrobial stewardship in mandatory IPC training

In most cases, pharmacists formed the majority of the antimicrobial stewardship workforce. There were also trusts that reduced their Watch and Reserve antibiotic consumption who reported no change in their workforce and capacity.

6. A supportive prescribing infrastructure facilitated and reinforced antimicrobial stewardship

Optimisation of drug charts, digital systems’ antimicrobial stewardship functionality, and accessible guidelines (desktop or mobile device) were reported as facilitators by trusts that reduced and increased their Watch and Reserve antibiotic consumption. Respondents shared practical ways they adapted drug charts and digital systems to enhance antimicrobial stewardship:

• ARK-aligned antibiotic sections on drug charts with time limited initial therapy followed by re-prescription if continued treatment is needed post review
• introduction of automatic “hard stops”: Fixed durations for antibiotic prescriptions, such as 5 days treatment for hospital acquired pneumonia
• mandatory order sets for specific situations: For example, a sepsis bundle that prompts the clinician to complete a set of actions before prescribing.
• automated prompts: To review intravenous antibiotics at 72 hours, with links to pathology results
• ICNet digital system module for antimicrobial stewardship: Enables reporting of antibiotic use at the patient level for prioritisation of intervention
• Direct documentation of microbiology advice on electronic prescribing system: clear communication of plans with rationale helps teams to follow advice

7. Visible antimicrobial stewardship leadership was a key driver for change

A trusted and influential antimicrobial stewardship lead was a key facilitator in organisations that reduced Watch and Reserve antibiotic use. These individuals built constructive relationships with clinical teams and adapted messaging to emphasise patient outcomes and efficiency rather than solely antimicrobial resistance.

Trusts that reduced their Watch and Reserve antibiotic consumption actively raised the antimicrobial stewardship profile through consistent clinical engagement, whereas trusts that increased their Watch and Reserve antibiotic consumption often cited lack of visibility and resourcing as barriers. Activities that contributed to effective antimicrobial stewardship leadership included:

• frequent ward presence through regular face-to-face ward rounds and stewardship visits
• introduction of “Time-Out” reviews implemented in rotation across wards
• participation in regular multi-disciplinary team meetings; for example, for bone and joint infections or outpatient parenteral antimicrobial therapy (OPAT)
• provision of adaptive feedback to clinicians for example, “authoritative for surgeons and consultative for medical”
• empowered antimicrobial stewardship and ward pharmacists reinforcing guidelines and confidently challenging prescribing decisions

8. Available and pro-active microbiology leadership is fundamental and can catalyse antimicrobial stewardship

Available and pro-active microbiology leadership that consistently applied antimicrobial stewardship principles and enabled refinement of laboratory practices was a common feature in trusts that reduced Watch and Reserve antibiotic use and a common barrier for those that increased their Watch and Reserve consumption.

Key contributing activities to facilitate antimicrobial stewardship included:

• regular microbiologist presence on site or weekly ward rounds
• selective reporting of susceptibility results by laboratories, with provision of specific antimicrobial stewardship advice including intravenous to oral switch options, treatment durations and outpatient parenteral (e.g. intravenous) antimicrobial therapy (OPAT) suggestions
• empowering resident doctors to consult microbiology for guidance, including in situations where they may need to question a consultant’s prescribing decision
• using screening to exclude colonisation with resistant organisms, which supports de-escalation and avoids unnecessary escalation, for example rectal screening for septic patients
• promoting use of carbapenem-sparing strategies
• introduction of diagnostics such as Mast Uri® system that enables susceptibility testing to 12 antibiotics simultaneously, which provides results quicker (24 hour) with more options for de-escalation to antibiotics from the Access category.

9. Senior leadership and clinical engagement can help to make a difference but was often limited and not always consistent

Engaging staff across all levels from board to ward supported Watch and Reserve reduction, though formal antimicrobial stewardship champion networks were rare. While most engagement factors were similar between organisations that reduced or increased Watch and Reserve use, one clear difference stood out: medical and surgical consultant engagement. This was reported as a key facilitator by 71% of trusts that reduced their Watch and Reserve antibiotic consumption – more than double the 30% reported by trusts that increased their Watch and Reserve consumption. Support from trust senior clinical leadership such as the medical director, chief nurse and chief pharmacist were reported as a facilitator, especially when they were able to engage using patient outcome related drivers such as antimicrobial stewardship to reduce Clostridioides difficile infections. Engagement from Trust boards was generally mixed with some reporting the importance of the Board in enabling resources for antimicrobial stewardship to be prioritised and others reporting lack of interest due to a focus on finances and being more reactive than proactive or preventative in their prioritisation of activities.

Barriers to reducing Watch and Reserve consumption

A range of barriers to reducing Watch and Reserve consumption were also reported, many of which reflect the absence of known facilitators. However, some additional distinct challenges were reported:

• challenges with acceptance of AMS recommendations: perceived factors reported include medical hierarchy, being a relatively junior or new member of staff and being a female member of staff of colour
• impact for laboratories of new European EUCAST breakpoints: Implementation led to higher recommended antibiotic doses to achieve therapeutic exposure, contributing to increased Watch and Reserve use
• limitations in susceptibility reporting: laboratories were unable to report susceptibility results for specific organism-antibiotic combinations (for example, fosfomycin or temocillin in Gram-negative bloodstream infections) due to the absence of EUCAST breakpoint rules, despite clinical evidence supporting their use
• outsourced microbiology services: where microbiology support was provided by external organisations, interviewees noted limited antimicrobial stewardship engagement, inconsistent guideline use, and reduced accountability for the serviced organisation’s antimicrobial stewardship priorities (for example, fluoroquinolone reduction)
• lack of shared ownership for antimicrobial resistance: antimicrobial stewardship leads reported a perception that antimicrobial resistance was not a shared responsibility, with limited engagement from both senior leadership and frontline medical staff. Concerns raised by antimicrobial stewardship teams were often not addressed, and consistent involvement from clinicians remained a challenge
• stock issues with electronic storage systems: inadequate restocking led to occasional reliance on third- and fourth-line agents when first-line options were unavailable
• lack of robust approach to inappropriate prescribing: trusts reported having limited or no formal processes to challenge or escalate leaving antimicrobial stewardship teams without effective levers to promote accountability or behaviour change

Future plans in trusts that reduced Watch and Reserve consumption

Despite already achieving reductions, trusts planned to maintain focus on Watch and Reserve antibiotic use. Planned activities included:

• operational improvements: implementation and optimisation of EPMA, addressing supply chain issues, and exploring artificial intelligence tools
• workforce initiatives: recruitment, enhanced education and training, and medical and nursing antimicrobial stewardship champions
• optimising patient management: improving management of community-acquired urinary tract infections, refining treatment durations, strengthening diagnostic stewardship, targeting meropenem and piperacillin/tazobactam use, delabelling spurious penicillin allergy labels, and using genomics to support de-escalation in intensive care units
• strategic actions: working with trust quality improvement teams, focusing on targeted areas for improvement, developing long-term antimicrobial stewardship plans, and involving pharmacists from other specialties to support antimicrobial stewardship objectives within their clinical areas

Best practice recommendations

Rising Watch and Reserve antibiotic consumption is not inevitable; numerous trusts have successfully reduced consumption, even from a low baseline. Based on insights from qualitative interviews, the following actions are suggested for consideration by organisations aiming to reduce Watch and Reserve consumption:

• Strategy: develop a targeted antimicrobial stewardship strategy with a clear focus on reducing Watch and Reserve use, supported by a workplan to deliver reduction
• Guidelines: review and update prescribing guidelines to prioritise narrow-spectrum antibiotics for empirical therapy, include clear intravenous-to-oral switch guidance, specify evidence-based course lengths, and improve accessibility of guidelines for point-of-care use which may include use of software applications
• Data: use data to identify areas of high Watch and Reserve use where there is limited antimicrobial stewardship or infection specialist oversight, to help target improvement efforts effectively
• Digital: optimise digital infrastructure to support antimicrobial stewardship, aligned with recommendations in the Digital Vision for Antimicrobial Stewardship
• Workforce: benchmark performance and ensure adequate antimicrobial stewardship resourcing
• Leadership (clinical): ensure antimicrobial stewardship team visibility in clinical areas by building strong, trusted relationships with frontline staff and making effective use of multidisciplinary expertise
• Leadership (executive): engage clinical leaders and executives to embed antimicrobial stewardship at all levels of the organisation

Best practice examples

Some examples of best practices shared by trusts are highlighted below.

Redesigning antibiotic guidelines to support behaviour change A district general hospital applied behaviour change principles to redesign its antibiotic guideline smartphone app. The updated layout uses a psychologically informed structure, guiding users step-by-step to the appropriate advice. For example, users must calculate a severity score for community acquired pneumonia before accessing treatment recommendations, ensuring relevant clinical decision-support is integrated into prescribing decisions.

Using data to drive improvements in antibiotic prescribing A large teaching trust, having already made substantial progress in antimicrobial use, used Refine (reporting via Rx-info) to monitor consumption trends more closely. This enabled them to identify specific issues, such as high co-amoxiclav use in one department, and implement targeted improvement efforts.

Providing and discussing personalised feedback to tackle causes inappropriate antibiotic prescribing A specialist trust introduced personalised feedback following audits where prescribing did not align with guidance. Antimicrobial stewardship teams followed up with prescribers via email or in person to understand contributing factors and provide education where needed. This approach strengthened relationships with clinical teams and improved engagement with stewardship principles.

Glossary

• Antimicrobial Stewardship – the term ‘antimicrobial stewardship’ is defined as ‘an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness’. [NICE guideline NG 15]
• ARK – Antibiotic Review Kit – a suite of resources to support clinicians in secondary care stop unnecessary antibiotics promptly.
• De-escalation – refers to the amendment of antimicrobial therapy either by reducing the number of antimicrobials prescribed, reducing their spectrum of action to narrower spectrum choices, changing the route of administration from intravenous to oral or a combination of these actions.
• Defined daily doses – a statistical measure of drug consumption, defined by the World Health Organisation; it is the assumed average maintenance dose per day for a drug used in its main indication in adults.
• Diagnostic stewardship – the process of modifying the ordering, performing or reporting of diagnostic tests to improve the diagnosis and treatment of infections.
• EUCAST – European committee on antimicrobial susceptibility testing.
• Hard stop – refers to the automated discontinuation of an antimicrobial in an electronic prescribing and medicines administration system once a defined treatment duration has been reached.
• Watch and Reserve – antibiotics from the “Watch” and “Reserve” categories, as defined by the UK-AWaRe antibiotic classification, adapted from the World Health Organisation antibiotic categorisation.
• UKHSA – The United Kingdom Health Security Agency.

Acknowledgements

The Antimicrobial Resistance Programme Antimicrobial Prescribing and Medicines Optimisation Team would like to thank all the interviewees for contributing their time and sharing their experiences.

Publication reference: PRN02449ix