Antimicrobial stewardship

Quick Overview

Antimicrobial stewardship is the systematic approach to optimizing antimicrobial use to improve patient outcomes, reduce resistance, and minimize adverse effects. NICE NG15 provides the START SMART THEN FOCUS toolkit, emphasizing structured prescribing decisions, documentation, and regular review. This is essential for safe prescribing and infection management across all healthcare settings.

Core Facts & Concepts

START SMART THEN FOCUS Framework

• START SMART (Initiation - 5 key decisions):

  • Do NOT start antibiotics without clinical evidence of infection
  • Take cultures before antibiotics (if possible without delay)
  • Follow local guidelines and formulary
  • Document indication, drug choice, dose, route, duration in notes
  • Prescribe for ≤72 hours initially (review date mandatory)

• THEN FOCUS (Review at 48-72 hours - 5 actions):

  • STOP if no evidence of infection
  • Switch IV to oral (if clinically improving + oral route functional)
  • Change antibiotic based on culture results
  • Continue and document next review date
  • OPAT (Outpatient Parenteral Antimicrobial Therapy) if appropriate

Critical Documentation Requirements (NICE NG15)

• 📊 Indication (clinical diagnosis + severity)
• 💊 Drug name, dose, route, frequency
• 📅 Review/stop date (within 72 hours)
• 🔬 Microbiology samples sent (yes/no)
• 🎯 Treatment duration (total days planned)

Problem-Solving Approach

Step-by-Step Prescribing Decision

1. Clinical diagnosis confirmation

   • 🚩 Fever + source identified + severity assessment
   • Sepsis screening if systemically unwell

2. Sample collection (pre-antibiotic if safe)

   • Blood cultures (2 sets), urine, sputum, wound swabs
   • Delay antibiotics ≤1 hour acceptable if non-septic

3. Empirical antibiotic selection

   • Use local formulary first-line agents
   • Consider allergy status, renal/hepatic function
   • Narrow spectrum preferred unless septic

4. 48-72 hour mandatory review

   • Check culture results, inflammatory markers (CRP trend)
   • Apply THEN FOCUS actions (see flowchart below)

5. IV to oral switch criteria (all must apply):

   • Clinical improvement (afebrile >24h, haemodynamically stable)
   • Oral route functional (not vomiting, conscious)
   • Oral bioavailability adequate for infection site

⚠️ Warning: Failure to document review dates is the most common stewardship violation

Analysis Framework

Red Flags for Antimicrobial Resistance Risk 🚩

• Previous MRSA/ESBL/CPE colonization
• Recent hospitalization (≤3 months)
• Recent antibiotic use (≤3 months)
• Healthcare-associated infection
• Travel to high-resistance areas

Visual Aid

Local Antimicrobial Governance Structure

• Antimicrobial Pharmacist - daily ward reviews, IV-oral switches
• Microbiology Consultant - complex case advice, resistance surveillance
• Infection Control Team - outbreak management, isolation policies
• Formulary Committee - local guideline updates, restriction policies

Key Points Summary

✓ START SMART THEN FOCUS is the NICE NG15 core toolkit - memorize the 5+5 structure

✓ Mandatory documentation: indication, drug, dose, route, review date (≤72 hours)

✓ 48-72 hour review is non-negotiable - apply one of 5 FOCUS actions (Stop/Switch/Change/Continue/OPAT)

✓ IV to oral switch when afebrile >24h + oral functional + clinically improving

✓ Take cultures before antibiotics unless septic (then delay ≤1 hour maximum)

✓ Resistance risk factors: recent antibiotics/hospitalization, healthcare setting, previous MDR organisms

✓ Common pitfall: Completing arbitrary "courses" instead of stopping when infection ruled out

📌 Remember: The best antibiotic stewardship decision is often to NOT prescribe