Improving the quality of antibiotic prescribing in the nhs by developing a new antimicrobial stewardship programme: Start smart-then focus

Diane Ashiru Oredope, Mike Sharland, Esmita Charani, Cliodna McNulty, Jonathan Cooke*

*Corresponding author for this work

    Research output: Contribution to journalArticlepeer-review

    197 Citations (Scopus)


    There has been dramatic change in antibiotic use in English hospitals. Data from 2004 and 2009 show that the focus on reducing fluoroquinolone and second- and third-generation cephalosporin use seems to have been heeded in NHS secondary care, and has been associated with a substantial decline in hospital Clostridium difficile rates. However, there has been a substantial increase in use of co-amoxiclav, carbapenems and piperacillin/tazobactam. In primary care, antibiotic prescribing fell markedly from 1995 to 2000, but has since risen steadily to levels seen in the early 1990s. There remains a 2-fold variation in antimicrobial prescribing among English General Practices. In 2010, the NHS Atlas of Variation documented a 3-fold variation in the prescription of quinolones and an 18-fold variation in cephalosporins by Primary Care Trusts across England. There is a clear need to improve antimicrobial prescribing. This paper describes the development of new antimicrobial stewardship programmes for primary care and hospitals by the Department of Health's Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection: Antimicrobial Stewardship in Primary Care Initiative. The secondary care programme promotes the rapid prescription of the right antibiotic at the right dose at the right time, followed by active review for all patients still on antibiotics 48 h after admission. The five options available are to stop, switch to oral, continue and review again, change (if possible to a narrower spectrum) or move to outpatient parenteral antibiotic therapy. A range of audit and outcome tools has been developed, but to maintain optimal antimicrobial usage, monitoring of local and national quantitative and qualitative data on prescribing and consumption is required, linked to the development of key performance indicators in primary, secondary and tertiary care.

    Original languageEnglish
    Article numberdks202
    Pages (from-to)i51-i63
    JournalJournal of Antimicrobial Chemotherapy
    Issue numberSUPPL.1
    Publication statusPublished - Jul 2012

    Bibliographical note

    Funding Information:
    This article forms part of a Supplement sponsored by the BSAC and the British Infection Association.

    Funding Information:
    (NIHR) Biomedical Research Centre Funding Scheme at Imperial College, support from the Centre for Infection Prevention and Management (CIPM) funded by the UKCRC and the Centre for Patient Safety and Service Quality (CPSSQ) funded by the NIHR.

    Funding Information:
    APREC ( was launched in 2010 by the European Society of Pediatric Infectious Disease and is funded by the Directorate-General for Health and Consumers (DG SANCO) specifically to improve the quality of community and hospital antibiotic prescribing in children. The key aim of the project is to collect and then use local and regional data in educational initiatives focusing on improving prescribing.


    • Antibiotic
    • Antimicrobial stewardship programme
    • NHS


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