The UK has made measurable progress in tackling antimicrobial resistance, but challenges remain around prescribing behavior, data infrastructure, and public awareness, according to Professor Diane Ashiru-Oredope, Lead Pharmacist for healthcare associated infections and antimicrobial resistance at the UK Health Security Agency. She outlined the country’s efforts in a wide-ranging discussion covering the national action plan, stewardship tools, and lessons learned from the COVID-19 pandemic.
UK’s five-year plan and the pandemic’s impact on stewardship
The government published its first antimicrobial resistance strategy in 2013, followed by a 20-year vision and a five-year national action plan covering 2019 to 2024. An addendum in May 2022 updated those commitments based on pandemic lessons and progress toward sector targets.
COVID-19 hit routine antimicrobial stewardship activities hard. A UK-wide survey found that 64% of antimicrobial stewardship leads reported a negative impact on their usual work. The pandemic also showed how quickly an infectious disease can disrupt normal life and healthcare delivery, Ashiru-Oredope noted.
She said new methods for communication and collaboration among stewardship teams, infection prevention programs, and IT departments should continue even as healthcare systems return to pre-pandemic patterns.
Challenges of antimicrobial stewardship across different settings
Hospital-based stewardship programs are relatively well established, though not without their own problems. But implementing those programs in long-term care facilities, outpatient clinics, and community pharmacies brings extra hurdles.
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Key challenges include the need for significant resources: multidisciplinary specialist teams, engaged frontline healthcare workers, diagnostic capacity, IT infrastructure, and training for both professionals and the public. In non-hospital settings, there are fewer microbiology and stewardship specialists available to lead programs.
Frontline clinicians sometimes resist stewardship interventions because they see them as an added burden or a limit on their ability to care for patients. Time pressure is a recurring theme — adding CRP point-of-care testing to a consultation is tough when slots are short, and some electronic tools take too long to use. General practitioners also report that elderly patients without internet access can’t receive email information sheets or be directed to online resources.
Getting timely data on antimicrobial use and resistance remains a challenge across sectors, even though Britain has relatively rich data compared to some countries. Coordination across care settings is difficult, though the new Integrated Care Systems model may help.
In other parts of the world, the problems are even starker: weak regulatory enforcement and a near-total lack of data infrastructure for tracking antibiotic use and resistance.
Antibiotic prescribing locations
In England, 72.1% of antibiotics are prescribed in general practice and dispensed through community pharmacies. Hospital inpatients account for 13% of prescriptions, hospital outpatients 6%, dental practices 4%, and other community settings another 4%. Stewardship efforts have been concentrated in acute hospitals and primary care for years, but community pharmacy has received more attention recently.
A notable example is the TARGET antibiotic checklist, part of England’s Pharmacy Quality Scheme from September 2021 to May 2022. A total of 8,374 pharmacies — 88% of all community pharmacies in England — submitted data from 213,105 checklists. Pharmacy staff used the checklist to ask patients about their infection, risk factors, allergies, and antibiotic knowledge. They also provided 69,861 patient information leaflets.
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Causes of antimicrobial misuse and overuse
Misuse is rarely intentional.
Ashiru-Oredope said behavioral science helps explain the drivers. Patients and even some healthcare workers lack awareness of what antimicrobials can and cannot do — for instance, the idea that antibiotics cure viral infections like colds is still common. Fear of patient deterioration drives prescribing: a 2019 EU-wide study found that 31% of prescribers said they had prescribed an antibiotic they would rather not have in the previous week, with 43% saying fear of complications affected their decisions at least once a week.
Perceived pressure from patients or parents plays a role. Diagnostic uncertainty also contributes — it’s genuinely hard to tell viral from bacterial infections, and guidelines don’t always align with clinical judgment. Communication skills training, including internet-based programs tested across five European countries, has been shown to reduce antibiotic prescribing for respiratory tract infections.
Quantifying the burden of AMR itself is technically demanding. UKHSA has helped develop analytical methods to measure health and economic impacts, which feed into evaluations of intervention strategies.
Public understanding matters more than most people think
Patients influence prescribing in primary care, and behaviors like self-medication with leftovers or buying antibiotics online also drive resistance. Public health campaigns face a tricky problem: AMR is complex, there’s no single simple behavior to target, and messaging has to avoid discouraging people from seeking help when they actually need it.
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Interim survey findings from England during the pandemic showed that restrictions changed health-seeking behavior, with more self-management for respiratory tract infections. The results also highlighted the need to focus on groups affected by health inequalities — people with disabilities, those in socially deprived areas, minority ethnic groups, and younger adults.
Systematic reviews have shown that intervention effectiveness depends heavily on local prescribing behavior and the specific barriers in a community. Complex educational programs only work after those local barriers have been addressed, Ashiru-Oredope said.
Interventions that have actually moved the needle
Total antibiotic use in England has fallen over the last decade, reversing a trend that saw increases every year from 2008 to 2013 — a 16.6% rise over that period. National interventions credited with driving the change include the Start Smart then Focus toolkit for hospitals, which outlines evidence-based stewardship activities in secondary care. The TARGET toolkit for primary care targets prescribers’ attitudes and social norms around antibiotic use.
The e-Bug program, launched in 2009 after an EU-wide needs assessment, teaches children and young people about hygiene, infection spread, and antibiotic use. It is now endorsed by the National Institute for Health and Care Excellence, which recommends all schools use it. Clinical guidelines from NICE and SIGN support stewardship efforts in both primary and secondary care.
The Antibiotic Guardian campaign, which the lead pharmacist helped create in 2014, uses an implementation intention approach — “if X happens, then I will do Y.” Evaluations show it increased commitment to tackling resistance, self-reported knowledge, and behavior change, especially among people who already knew something about the problem. A national consensus for IV-to-oral switch criteria has also been developed recently.
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