Antimicrobial Stewardship — UKMLA Guide 2026

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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

Antimicrobial resistance (AMR) is a global health emergency — the UK 5-year AMR strategy aims to reduce antibiotic use by 15%
NICE NG15: use local antibiotic guidelines, prescribe narrowest spectrum, shortest effective course, and review at 48–72 hours
"Start Smart, Then Focus" (NHSE): empirical antibiotics within 1 hour for sepsis → review at 48 hours → stop, switch IV-to-oral, narrow, or change
Send cultures BEFORE starting antibiotics (but do NOT delay treatment for culture results in sepsis)
Key consequences of inappropriate antibiotic use: C. difficile infection, MRSA selection, multidrug-resistant organisms, adverse drug reactions

Overview

Antimicrobial stewardship is a coordinated programme of interventions to optimise antimicrobial use. The goals are to achieve the best clinical outcomes, minimise toxicity and adverse effects, reduce selection pressure for antimicrobial resistance, and reduce costs. The "Start Smart, Then Focus" framework guides hospital antibiotic prescribing: start empirical antibiotics promptly in infection, then review at 48–72 hours with culture results and clinical progress to stop, switch to oral, narrow the spectrum, or change based on sensitivities. Every antibiotic prescription should have a documented indication, planned duration, and review date.

Epidemiology

The UK uses approximately 34 defined daily doses (DDD) of antibiotics per 1,000 population per day. Approximately 20–30% of antibiotic prescriptions in primary care are estimated to be unnecessary. AMR is projected to cause 10 million deaths globally per year by 2050 if not addressed. C. difficile infection, a direct consequence of antibiotic use, causes approximately 15,000 cases and 1,500 deaths per year in England.

Clinical Features

Symptoms

This topic covers prescribing principles rather than a clinical condition

Signs

Signs of treatment failure despite antibiotics may indicate resistance or wrong antibiotic choice

Investigations

First-line

Blood culturesTake BEFORE starting antibiotics in suspected sepsis (2 sets from different sites)

Culture and sensitivity from relevant siteUrine, sputum, wound swab, CSF — enables targeted (narrow-spectrum) therapy

CRP and procalcitoninHelp differentiate bacterial from viral infection and guide antibiotic duration

Second-line

Local antibiogramHospital-specific resistance patterns guide empirical prescribing

Management

NICE NG15 (Antimicrobial stewardship) + NHSE Start Smart Then Focus

Start Smart

Do not start antibiotics without clinical evidence of bacterial infection (unless life-threatening sepsis)
Start empirical antibiotics per LOCAL guidelines — narrow spectrum where possible
Document: indication, antibiotic choice, dose, route, duration, and review date on the drug chart
Send cultures BEFORE starting antibiotics
In sepsis: start IV antibiotics within 1 hour of recognition

Then Focus (review at 48–72 hours)

STOP if no evidence of infection
SWITCH IV-to-oral if clinically improving, afebrile, and tolerating oral
NARROW spectrum based on culture sensitivities
CHANGE if not improving — reassess diagnosis, consider resistant organisms, discuss with microbiology
CONTINUE only if clear indication with planned stop date

Key stewardship principles

Use the shortest effective course (many infections now have evidence for shorter courses — e.g. 5 days for CAP)
Avoid broad-spectrum antibiotics (co-amoxiclav, ciprofloxacin, cephalosporins, carbapenems) unless clearly indicated — highest C. difficile risk
IV-to-oral switch criteria: afebrile >24h, improving clinically, able to tolerate oral, no indication for ongoing IV (e.g. endocarditis)
Allergy clarification: many "penicillin allergies" are not true allergies — confirm the nature of the reaction

Complications

Antimicrobial resistance: MRSA, ESBL-producing Enterobacteriaceae, carbapenem-resistant organisms, MDR-TB
C. difficile infection: Directly caused by antibiotic use — particularly broad-spectrum agents
Drug adverse effects: Tendon rupture (fluoroquinolones), nephrotoxicity (gentamicin), ototoxicity (aminoglycosides)

UKMLA Exam Tips

1"Start Smart, Then Focus": empirical → review at 48h → stop/switch/narrow/change/continue
2Send cultures BEFORE antibiotics — but do NOT delay treatment for culture results in sepsis
3IV-to-oral switch when: afebrile, improving, tolerating oral — reduces line infections, cost, and length of stay
4Shortest effective course: CAP 5 days, UTI 3 days (uncomplicated), cellulitis 5–7 days
5C. difficile risk is highest with: co-amoxiclav, ciprofloxacin, cephalosporins, clindamycin (the "4 Cs")
6Always check local antibiotic guidelines — resistance patterns vary between hospitals
7Penicillin allergy: ~90% of reported penicillin allergies are NOT true IgE-mediated — clarify the reaction

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