Antimicrobial Stewardship

Antimicrobial stewardship (AMS) refers to any action that promotes responsible use of antimicrobials.

AMS can also be defined as a set of coordinated interventions designed to improve and measure the appropriate use of antimicrobials.

The purpose of AMS is to: 

• support delivery of the right antimicrobial, at the right time, dose and duration to meet patients’ needs
• protect patients from avoidable harm related to inappropriate antimicrobial use
• ensure that antimicrobials remain effective for the future by limiting the emergence of antimicrobial resistance

AMS is an integral component of any patient safety programme. All healthcare professionals are antimicrobial stewards. Knowledge, awareness, and participation of everyone involved in the care of patients, in all care settings, is key to creating a culture that support staff to understand antimicrobials and generates behaviours that improve their use. 

What is antimicrobial resistance (AMR)? 

Antimicrobials are medicines used to prevent and treat infections in humans, animals and plants. Antimicrobials include antibacterials (most commonly referred to as antibiotics), antivirals, antifungals and antiparasitics. 

HSE RESIST Antimicrobials Infographic.pdf (size 146.8 KB)

Antimicrobial resistance (AMR) occurs when the microorganisms change or mutate over time and get to a point where they no longer respond to medicines previously used to treat them. AMR is driven by high rates of antimicrobial prescribing and it is critical that we work to reduce unnecessary antimicrobial use.

A One Health response at global and local level is essential in order to address the challenge of AMR. The One Health approach recognises that the health and well-being of people is connected to the health and welfare of animals, biodiversity, and the environment. We need to use less antimicrobials in every sector and use them more appropriately when we need to use them. 

One health Infographic (2021, Department of Agriculture, Food and Marine & Department of Health) (size 276.2 KB)

To learn more about the One Health approach view Ireland’s Second One Health National Action Plan on Antimicrobial Resistance 2021-2025. 

Why is antimicrobial stewardship (AMS) important? 

Antimicrobial resistance (AMR) has been recognised as one of the greatest potential threats to human and animal health over the last decade.

Over the last 20 to 30 years we have seen many antimicrobials become less effective or even not effective at all for treatment of some bacterial infections due to AMR.  This pushes us to use different antimicrobials that may be more toxic, more difficult to use and more costly. Patients with antimicrobial resistant infections are sicker for longer and require more complex care.  Effective antimicrobials are essential to the practice of modern medicine.

High levels of antimicrobial use and inappropriate use of antimicrobials causes increasing AMR as well as other patient harms.  Antimicrobial stewardship (AMS) is vital in limiting and potentially reversing the development of AMR so that antibiotics are kept effective for future generations. 

Practices that support good AMS

Preferred antibiotic use in the community green/red table

• Preferred antibiotic use in the Community Green/Red Table: Version 4 of the preferred antibiotic mouse mat is still valid for use and does not need to be replaced or disposed of. Single copies of the Version 5 mouse mat or a max of 5 copies for healthcare professionals can be ordered on healthpromotion.ie.

All healthcare professionals can support AMS by adhering to the 8 principles of good AMS;

1. Recognise clinical evidence of infection. For example, consider the signs and symptoms and whether they might represent infection.
2. Avoid unnecessary antimicrobial use. For example, recommend symptom relief for self-limiting infections, with safety netting advice, and direct patients and carers to information on common illnesses
3. Choose an antimicrobial that will have the most benefit and cause the least harm. For example, use best-practice treatment guidelines on www.antibioticprescribing.ie, using a ‘green’ antimicrobial in preference to a ‘red’ antimicrobial if an antimicrobial is needed.
4. Optimise the dosing regimen and route. For example, ensure patient is prescribed correct dose, frequency and route.
5. Minimise the duration. For example, avoid unnecessary prolonged courses of antimicrobials.
6. Assess response to treatment. For example, review any available microbiological sample results to guide treatment.
7. Communicate effectively about antimicrobials. For example, discuss the issue of AMR with patients
8. Prevent infection. For example, arrange vaccination and use IPC measures.

Healthcare professionals can also engage in regular education relating to AMS and participate in local or national quality improvement audits for antimicrobial use.

AMS Resources and Audit Tools 

AMS Audit Tools

Introduction to AMS audit and quality improvement

A quality improvement (QI) audit collects data on a small number of subjects, focusing on key measures of quality of prescribing. QI audits are usually designed to be simple so that they are easy to repeat periodically.  This will enable services to document improvement in practices over time and feed into the plan–do–study–act model of QI. Data for improvement measured regularly can be visually displayed with use of run-charts.

Model for Improvement	PDSA Cycle

Auditing the quality of prescribing can provide assurances that the most effective therapy is being given and that the risk of poor outcomes (including antimicrobial-related adverse events) is being reduced.

Clinical audit allows problem areas to be targeted and enables more intensive examination, leading to further interventions to improve prescribing.

Audit Tools

Preferred antibiotic audit tool

The Preferred antibiotics audit tool involves a self-audit of 10 antimicrobial prescriptions, and encourages general practitioners to reflect on their prescribing behaviour relative to current best-practice guidelines.

An example of a quality improvement project that used this audit tool model is the Out of Hours Antibiotic Stewardship Improvement Project.

• Demonstrating Quality improvement in Action : Audit tool 
• Improving the quality of antibiotic prescribing through an educational intervention delivered through the out of hours general practice service in Ireland

Antibiotic UTI prophylaxis audit tool 

The aim of this UTI prophylaxis audit tool is to enable review of patients currently prescribed antimicrobials for prophylaxis of urinary tract infections (UTIs). Further instructions and guidance can be found within the tool. You can download and use the antibiotic UTI prophylaxis audit tool here:

• Audit UTI Prophylaxis (Excel Tool).xlsm (size 79.3 KB) which has auto-analysis. Please note the electronic tool is a macro-enabled file. Depending on your version of excel, you may receive prompts to ‘Enable Editing’ and ‘Enable Content’ for optimal functionality.
• Audit Tool for UTI Prophylaxis (Word Version).pdf (size 261.9 KB)

Azithromycin prophylaxis in adults with respiratory disease audit tool 

The azithromycin prophylaxis audit tool is available to support healthcare professionals reviewing patients on azithromycin prophylaxis. For more information, visit the azithromycin prophylaxis in adults with respiratory disease guideline page.

Surgical antibiotic prophylaxis audit tool 

An excel audit tool and a YouTube video explaining its use are available to support the implementation of the joint position statement on surgical antibiotic prophylaxis as part of a quality improvement project. For more information visit the Surgical Antibiotic Prophylaxis page.

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Reviewed April 2023