Antimicrobial stewardship: An imperative across all healthcare settings

Reference: October 2026 | Issue 10 | Vol 12 | Page 12

Antimicrobial resistance (AMR) is widely recognised as one of the most serious threats to global health. As once-reliable anti-microbial treatments become less effective, the management of common infections becomes more complex, and vulnerable patients face increased risks of prolonged illness, complications, and poorer outcomes.

The misuse and overuse of antimicrobials in hospitals, community care, long-term care, and outpatient settings are major contributors to this crisis.¹ More than 35,000 people die each year due to antibiotic resistance across Europe.²

According to the World Health Organization (WHO) 2025 Global Antibiotic Resistance Surveillance Report, one in six laboratory-confirmed bacterial infections worldwide in 2023 were resistant to standard antibiotic treatments, highlighting the urgent global need for robust antimicrobial stewardship (AMS) practices in all care settings.¹

In recognition of the urgent need to curb AMR, the HSE in Ireland developed the Antimicrobial Resistance and Infection Control (AMRIC) 2022-2025 guidance, which sets out a national framework for strengthening AMS across all areas of healthcare.

This guidance highlights the scale of the challenge and reinforces that effective stewardship must extend beyond prescribing decisions alone. It calls for a whole system, coordinated approach that integrates clinical, organisational, and public health strategies to reduce inappropriate antimicrobial use, and improve infection prevention and control.^3,4

AMRIC emphasises that AMS is not solely the responsibility of prescribers. Instead, it requires active engagement from the entire healthcare workforce, including pharmacy, microbiology, infection prevention specialists, healthcare assistants, and organisational leadership.

AMS is defined as a coordinated set of interventions designed to optimise the use of antimicrobial medications, ensuring that patients receive the appropriate agent, dose, route, and duration of therapy while minimising unnecessary use, toxicity, and resistance.^3,4

In practice, AMS encompasses activities that span patient assessment, appropriate prescribing, administration, monitoring, infection prevention, education, and evaluation of antimicrobial use.

In Ireland, the majority of antibiotic use occurs outside hospital settings, in community care, residential facilities, and outpatient clinics. These environments often lack the robust AMS oversight found in hospitals, making them particularly important targets for stewardship initiatives.⁵

Approximately 80 per cent of antibiotic prescribing in Ireland is conducted in general practice.⁶ Patient demands, expectation, familiarity with the clinician, and time restraints have been documented as key factors for overprescribing antibiotic therapy in general practice, despite clinical evidence suggesting when it is not necessary.⁷

Efforts to reduce unnecessary antibiotic prescribing in Ireland include education and training for prescribing healthcare professionals; implementing decision support tools; using point-of-care testing including C-reactive protein; and supporting evidence-based practice through audit and evaluation. Initiatives also promote delayed prescribing where possible, evaluating its effectiveness, identifying barriers, and enhanced adoption through behavioural science approaches.⁷

All prescribing healthcare professionals have an ethical responsibility to prescribe antibiotics judiciously to reduce the risk of resistance.⁸ This requires a comprehensive understanding of the core principles of antibiotic selection, including the underlying pathology, and the therapeutic characteristics of the prescribed agents, ensuring that treatment is evidence-based, safe, and cost-efficient.⁹

Ethical practice also includes a commitment to AMS and the responsibility to effectively communicate with and educate patients when antibiotics are not indicated.⁷ Practice standards, decision-making frameworks, clinical governance structures, and regulatory bodies outline the criteria for safe and effective prescribing practice.

Good prescribing practice should optimise patient outcomes, support patient care, and encourage treatment concordance and adherence, while considering clinical response, tolerability, and lifestyle factors. Patients should be included in clinical decision-making processes, informing them of available options, while ensuring that prescriptive practice is safe, evidence-based, appropriate, and in the patient’s best interest.^9,10

The HSE Medicines Management Programme, working in partnership with the AMRIC team, introduced a national preferred antibiotics initiative, commonly referred to as the green/red antibiotic list. This initiative forms a key component of Ireland’s national AMS strategy and aims to standardise antimicrobial prescribing across primary and community care.

By clearly identifying preferred first-line ‘green’ antibiotics, the system guides clinicians toward agents that are effective for common infections, have favourable safety profiles, and present a lower selective pressure for the development of antimicrobial resistance. This approach not only supports safer, evidence-based prescribing, but also reduces unwarranted variation in clinical practice.^5,13

The initiative is strengthened by the HSE AMRIC community antimicrobial prescribing guidelines, available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/, which provide detailed, condition-specific recommendations to support prescribers in choosing the most appropriate antimicrobial therapy.

These guidelines outline when preferred ‘green’ antibiotics should be used, the clinical indications they cover, optimal duration of therapy, and when alternative agents may be required. Equally important, the guidance highlights circumstances in which ‘red’ antibiotics should be avoided unless there is a clear, evidence-based rationale for their use, typically due to their broader spectrum, higher risk of adverse events, or greater potential to drive resistance.

Together, the preferred antibiotics list and accompanying guidelines promote consistency, improve patient safety, and help ensure that antimicrobial use in the community is appropriate, targeted, and aligned with national stewardship priorities.^5,12

Conclusion

Antimicrobial stewardship is a shared responsibility that extends across all healthcare disciplines and settings. In Ireland, the HSE AMRIC guidance recognises this potential and advocates for comprehensive, multi-setting implementation of AMS practices.

Through active engagement in patient assessment, specimen management, administration and monitoring, patient education, infection prevention, audit, and multidisciplinary collaboration clinicians can ensure that antimicrobial therapy is safe, effective, and appropriate.

Author Bios

Theresa Lowry Lehnen, RGN, PG Dip Coronary Care, BSc, MSc, RNP, PG Dip Ed (QTS), M Ed, PhD FFNMRSCI, Advanced Nurse Practitioner General Practice

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