Antimicrobial prescribing and stewardship

Diagnosis, microbiology, local guidance, spectrum, dose/duration, review/de-escalation and resistance.

Pre-prescribing foundation: this module develops knowledge and judgement for formal prescribing education; it does not authorise prescribing.

• Confirm indication before antimicrobial prescribing.
• Use local/national guidance and microbiology information appropriately.
• Consider spectrum, route, dose, duration and review together.
• Explain de-escalation and stopping when treatment is no longer indicated.
• Connect individual prescribing with antimicrobial resistance and public health.

Antimicrobial prescribing should begin with likelihood and severity of infection, not simply patient expectation.

Choice should consider local/national guidance, likely organism, resistance, allergy, organ function, interactions and source control.

Document indication, plan, duration and review; use the shortest effective course consistent with guidance.

Stewardship balances individual benefit with population consequences of resistance.

1. Define the clinical problem and whether prescribing is indicated.
2. Gather the patient-specific assessment and diagnostic information needed.
3. Check competence, professional authority and employer/service scope.
4. Compare reasonable options using current authoritative sources.
5. Agree the plan with the patient, including uncertainty and alternatives.
6. Prescribe accurately only when the decision is justified.
7. Document, monitor, review and safety-net.

Module emphasis: Confirm the infection syndrome and indication, use current local guidance and microbiology where relevant, document duration/review, and stop or narrow treatment when appropriate.

Scenario 1. A patient expects antibiotics for a likely self-limiting respiratory illness.

Reasoning prompt: Confirm the infection syndrome and indication, use current local guidance and microbiology where relevant, document duration/review, and stop or narrow treatment when appropriate.

Scenario 2. Culture results allow narrowing treatment but broad-spectrum therapy is continued.

Reasoning prompt: Confirm the infection syndrome and indication, use current local guidance and microbiology where relevant, document duration/review, and stop or narrow treatment when appropriate.

Scenario 3. Renal impairment is not considered when choosing antimicrobial dose.

Reasoning prompt: Confirm the infection syndrome and indication, use current local guidance and microbiology where relevant, document duration/review, and stop or narrow treatment when appropriate.

• Patients with infection symptoms need antibiotics.
• Broad-spectrum is safer because it covers more organisms.
• A longer course is always more effective.

• What clinical problem am I trying to solve, and is prescribing indicated?
• What information is missing before a safe decision can be made?
• Is this within my current competence, professional authority and employer/service scope?
• Which current authoritative medicine or guideline source should I check?
• What patient-specific factors change benefit, harm, dose, route or monitoring?
• What will I document, monitor, review and safety-net?
• When should I seek supervision, pharmacy advice, specialist input or urgent escalation?

Optional reflection: Without entering identifiable patient or employer information, identify one capability you would need to strengthen before prescribing independently in this area.

• Antimicrobial prescribing should begin with likelihood and severity of infection, not simply patient expectation.
• Choice should consider local/national guidance, likely organism, resistance, allergy, organ function, interactions and source control.
• Document indication, plan, duration and review; use the shortest effective course consistent with guidance.
• Stewardship balances individual benefit with population consequences of resistance.

Check current versions for time-sensitive decisions.

• NICE-02 - NICE: NG15 Antimicrobial stewardshipOpen official source
• BNF-01 - BNF / NICE: British National FormularyOpen official source
• RPS-01 - Royal Pharmaceutical Society: A Competency Framework for All Prescribers (2021)Open official source