National antimicrobial prescribing guidance
Antibiotic prescribing in the UK follows NICE and UKHSA stewardship: confirm need, choose narrow-spectrum first, and escalate by defined thresholds.
Applies to primary and secondary care prescribers in UK clinical practice.
National antimicrobial prescribing guidance in the UK is fundamentally structured around the core principles of antimicrobial stewardship, which aim to optimise the treatment of infections while minimising the emergence and spread of antimicrobial resistance, and is underpinned by key resources such as those from the National Institute for Health and Care Excellence (NICE) and the UK Health Security Agency (UKHSA). The overarching strategy is to reserve antibiotics for situations where they are clearly indicated, promoting their prudent use through a systematic approach that begins with a thorough clinical assessment to distinguish between bacterial and viral infections, utilising tools like feverPAIN or Centor scores for sore throat to guide decision-making in primary care. Before prescribing, clinicians are advised to consider delayed prescribing strategies for self-limiting conditions where the benefits of immediate antibiotics are uncertain, agreeing a plan with the patient to use the prescription only if symptoms do not improve as expected. When an antibiotic is deemed necessary, the choice should be guided by local formularies and resistance patterns, which are often summarised in local antimicrobial guidelines developed by regional antimicrobial stewardship committees; these resources typically recommend narrow-spectrum agents active against the likely pathogens as first-line choices to preserve the effectiveness of broader-spectrum options for more serious infections. Dosage and duration should be aligned with the latest evidence, favouring the shortest effective course to reduce selective pressure, and parenteral administration should generally be reserved for severe infections, hospital settings, or when oral intake is compromised, with a clear plan for switching to oral therapy as soon as clinically appropriate. For common infections such as community-acquired pneumonia, urinary tract infections, and skin and soft tissue infections, specific guidance exists on first-line and alternative agents, taking into account patient factors like allergies, renal function, and risk factors for resistant organisms such as recent healthcare exposure or travel. In secondary care, antimicrobial prescribing is further supported by multidisciplinary teams including microbiologists and pharmacists, with policies often requiring prospective approval for certain restricted antibiotics to ensure appropriate use. Patient communication is a critical component, involving clear explanations about the rationale for prescribing or not prescribing an antibiotic, the importance of adherence to the prescribed course, and advice on managing symptoms and preventing future infections. Regular review of prescribing data against local and national benchmarks is encouraged to identify areas for improvement, and clinicians have a responsibility to stay updated on emerging resistance trends and revised guidance through continuous professional development, ensuring that their practice contributes to the collective effort to safeguard the effectiveness of antibiotics for future generations.
Local NHS antibiotic guidelines
Local NHS antibiotic guidelines are essential tools for clinicians, providing region-specific, evidence-based recommendations that align with national principles while addressing local antimicrobial resistance (AMR) patterns, formulary availability, and service pressures, and their use is a cornerstone of antimicrobial stewardship; these guidelines are typically developed by local antimicrobial stewardship committees or networks, often in collaboration with microbiology and infectious disease specialists, and are designed to support decision-making for common infections encountered in primary care, secondary care, and out-of-hours settings, covering conditions such as respiratory tract infections, urinary tract infections, skin and soft tissue infections, and sepsis management, with recommendations that specify first-line and second-line antibiotic choices, including drug name, dosage, duration, and any special considerations for patient groups like those with penicillin allergies or renal impairment, while also incorporating local data on resistance rates for key pathogens such as Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae to ensure empirical therapy remains effective; these documents are dynamic and are regularly reviewed and updated, often annually, to reflect emerging resistance trends, new national guidance, and changes in the local formulary, and they are disseminated to all relevant prescribers through various channels including trust intranets, primary care newsletters, and integrated into electronic prescribing systems and decision support tools where possible; adherence to these local guidelines is crucial for optimising patient outcomes, minimising the risk of Clostridioides difficile infection and other adverse effects, and reducing the selection pressure that drives AMR, with audit and feedback mechanisms often in place to monitor prescribing patterns against the guideline standards, and clinicians are encouraged to familiarise themselves with their local guidelines, understand the rationale behind the recommendations, and use them as the first point of reference for antibiotic selection, consulting microbiology or infectious diseases specialists for complex cases, infections with unusual pathogens, or when patients fail to respond to first-line therapy, thereby ensuring that antibiotic use is both prudent and targeted.
Stewardship principles
Antibiotic stewardship in the UK is a critical component of clinical practice aimed at preserving the effectiveness of existing antibiotics by optimising their use, thereby combating antimicrobial resistance (AMR), a major public health threat. The core principles, as endorsed by national bodies, begin with the fundamental decision of whether an antibiotic is truly necessary, distinguishing between bacterial infections requiring treatment and viral or self-limiting conditions where antibiotics are ineffective and potentially harmful; this initial assessment should be guided by clinical history, examination, and, where appropriate and available, the use of point-of-care tests such as C-reactive protein (CRP) or procalcitonin to support decision-making, particularly in primary care settings for respiratory illnesses. When an antibiotic is deemed essential, the next principle is to select the right drug, which involves choosing a narrow-spectrum antibiotic that targets the most likely pathogen whenever possible, based on local resistance patterns and national formularies like the British National Formulary (BNF), thereby minimising collateral damage to the patient's microbiome and reducing the selection pressure for broad-spectrum resistance. The choice of agent should also consider patient-specific factors such as allergies, renal and hepatic function, potential drug interactions, and the severity of the infection, with broader-spectrum agents reserved for severe, life-threatening infections, hospital-acquired infections, or when resistance to first-line agents is likely or confirmed. The third key principle is to use the right dose and route, ensuring adequate therapeutic levels are achieved at the site of infection to maximise efficacy and minimise the risk of resistance development, with intravenous administration typically reserved for serious infections or when oral absorption is compromised, with a prompt switch to oral therapy as soon as clinically indicated, as supported by evidence demonstrating equivalent outcomes in many scenarios. The fourth principle is to prescribe for the right duration, avoiding unnecessarily long courses, as evidence increasingly shows that shorter courses are often as effective as longer ones for many common infections, such as community-acquired pneumonia, urinary tract infections, and cellulitis, with treatment duration being guided by the patient's clinical response rather than a predetermined arbitrary length; this approach reduces total antibiotic exposure and the associated risks. A cornerstone of stewardship is delayed or back-up prescribing, a strategy particularly valuable in primary care for conditions like acute otitis media, sore throat, and sinusitis where the diagnosis is uncertain or the illness is likely to be self-limiting; this involves providing a prescription with clear safety-netting advice for the patient to use only if their symptoms do not improve or significantly worsen after a specified period, effectively reducing immediate antibiotic consumption while safeguarding patient welfare. Integral to all these actions is effective communication with patients and their families, which involves explaining the rationale for not prescribing an antibiotic when appropriate, managing expectations, and discussing the risks of AMR in a clear and understandable way to ensure shared decision-making and maintain the therapeutic relationship. Finally, ongoing audit and reflection on personal prescribing habits against local and national data are essential for clinicians to understand their impact and identify areas for improvement, contributing to a collective effort across the NHS to safeguard these vital medicines for future generations.
Tools for accessing prescribing guidance
In the UK, clinicians have access to a robust suite of tools for accessing antibiotic prescribing guidance, which are essential for promoting antimicrobial stewardship and combating resistance; the primary national resource is the National Institute for Health and Care Excellence (NICE) guidelines, which provide comprehensive, evidence-based recommendations for managing common infections across primary and secondary care, detailing first-choice antibiotics, alternatives for penicillin allergy, and appropriate treatment durations, while also integrating advice on when not to prescribe antibiotics, and these guidelines are readily accessible online through the NICE website, which features a user-friendly search function and is regularly updated. Complementing NICE, the UK Health Security Agency (UKHSA) offers vital specialist guidance, particularly for managing complex scenarios such as suspected sepsis, infections in immunocompromised patients, and the treatment of specific organisms like MRSA, with their resources including detailed management algorithms and 'toolkits' for common clinical situations, all available on the UKHSA website. For primary care practitioners, the 'Treatments Summary' section within the British National Formulary (BNF) remains an indispensable, quick-reference tool, providing concise summaries of recommended antibiotic regimens for a wide array of infections, directly linked to prescribing information, and is accessible via the online BNF platform or the mobile app, ensuring guidance is available at the point of care. Local formularies, developed by regional Antimicrobial Management Teams (AMTs) or Integrated Care Systems (ICSs), are another critical tool, as they tailor national guidance to local resistance patterns and service availability, often providing streamlined pathways and approved antibiotic lists for hospitals and GP practices, and clinicians should familiarise themselves with their local formulary, which is typically accessible through their trust's or ICS's intranet. Furthermore, decision-support tools integrated into clinical IT systems, such as those within EMIS and SystmOne in primary care or electronic prescribing systems in hospitals, can prompt clinicians with guideline recommendations during the consultation or prescribing process, thereby embedding best practice directly into workflow. For managing specific patient groups, the Scottish Intercollegiate Guidelines Network (SIGN) and other devolved national bodies produce high-quality guidance that is also relevant for UK clinicians, particularly where it addresses areas not covered in depth by NICE, and these are similarly available online. In secondary care, consultation with local microbiology, infection prevention and control teams, or infectious diseases specialists remains a vital, interactive tool for complex cases, providing patient-specific advice that aligns with local resistance data. To stay current, clinicians are advised to periodically check the main guideline websites for updates, subscribe to relevant professional body alerts, such as those from the Royal College of General Practitioners or the British Infection Association, and utilise resources like the TARGET antibiotics toolkit from UKHSA, which contains patient leaflets and audit tools to support prudent prescribing. Ultimately, the effective use of these combined tools—national guidelines, local formularies, integrated IT support, and specialist advice—ensures that antibiotic prescribing is safe, effective, and aligned with the overarching goal of preserving these vital medicines for future generations.