Guidance

Antimicrobial prescribing and stewardship competency framework

Updated 16 August 2023

Applies to England

Purpose

The goal of the antimicrobial prescribing and stewardship (APS) competency framework is to improve the quality of antimicrobial treatment and stewardship and therefore reduce the risks of inadequate, inappropriate, and adverse effects of antimicrobial treatment. This will improve the safety and quality of patient care and make a significant contribution to the reduction in the emergence and spread of antimicrobial resistance (AMR).

Antimicrobial stewardship is an important element of the following:

• code of practice in England
• UK 20-year vision for AMR
• UK 5-year action plan for AMR

Introduction

AMR is a global and public health issue exacerbated by the overuse and inappropriate prescribing of antimicrobials, poor infection control and prevention practices, and global trade and travel (1).

The increase in resistance is making antimicrobial agents less effective and resulting in infections that are difficult to treat and a substantially increased risk of adverse outcomes for patients. The number of infections due to multidrug-resistant (MDR) organisms is growing. However, the number of novel antimicrobials being developed is extremely limited (2).

Antimicrobial stewardship initiatives aim to improve and monitor the prescribing of all antimicrobials, whether they target infections that are:

• bacterial
• viral
• fungal
• mycobacterial
• protozoal

The National Institute for Health and Care Excellence (NICE) defines antimicrobial stewardship as “an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness”.

AMR is deemed to be one of the top 10 global public health threats facing humanity by the World Health Organization (WHO). It could be especially dangerous towards children, older people, and those with weakened immune systems.

Effective antimicrobials have revolutionised many medical treatments, such as cancer chemotherapy and organ transplantation; these treatments require antibiotics to prevent and treat associated bacterial infections and increase the rate of survival. Without the availability of effective antimicrobials, common infections, which are now regarded as minor and easily treatable, may become untreatable. This would lead to prolonged illnesses, increased mortality rates, and higher healthcare costs (3).

Educating the public and clinicians in the prudent use of antimicrobials as part of an antimicrobial stewardship programme is of paramount importance to preserve these crucial treatments and to help control resistance. Improving surveillance, and infection prevention and control (IPC) are other key strategies (4).

The major goals for antimicrobial stewardship (5) are to:

• optimise antimicrobial therapy for individual patients
• prevent overuse, misuse, and abuse of antimicrobials
• minimise development of resistance at patient and community levels
• prevent unintended harm through adverse drug reactions and healthcare-association infections

An antimicrobial stewardship programme is an important component in tackling AMR by reducing healthcare associated infections, reducing costs, improving patient safety and outcomes (6 to 8).

A start smart then focus (SSTF) approach is recommended for all antimicrobial prescriptions in secondary care and utilisation of the Treat Antibiotics Responsibly, Guidance, Education and Tools (TARGET) toolkit is recommended for primary care.

Background

Competencies are described as a “combination of knowledge, skills, motives and personal traits”, development of which should help individuals to continually improve their performance and to work more effectively (9).

The APS competency framework and its contents are intended to be used in conjunction with a Competency Framework for all Prescribers, published on the Royal Pharmaceutical Society (RPS) website, and, in England, the Infection prevention and control education framework, published on NHS England’s website.

A Competency Framework for all Prescribers was published in 2016 and provides an outline framework of prescribing competencies that, if acquired and maintained, can “help healthcare professionals to be safe and effective prescribers who support patients in getting the best outcomes from their medicines”. It is intended for use by any independent prescriber, doctor, dentist or non‐medical prescriber. It is an update of the prescribing competency framework published by the National Prescribing Centre (NPC) and NICE in 2012. This original framework was based on earlier profession-specific prescribing competency frameworks and developed because it became evident that “a common set of competencies should underpin prescribing, regardless of professional background”.

The IPC education framework was commissioned by NHS England to outline the behaviours, knowledge and skills required by the health and social care workforce to improve the quality of IPC practices and improve patient outcomes. One of the key purposes of the IPC education framework is enable staff to understand and demonstrate the required expectations for effective and safe IPC practice.

The 6 competency domains within the APS competency framework complement the RPS Competency Framework for all Prescribers and the IPC education framework. Each has an overarching statement and corresponding descriptors that describe the activity, knowledge, or outcome that prescribers should be able to demonstrate. The update process for the APS competency framework is detailed in Appendix 1.

Using the APS competency framework

The APS competency framework can be used by both medical and non-medical prescribers in any care setting to support the development of their prescribing practice at any point in their professional development in relation to prescribing antimicrobials and embodying stewardship practices.

To understand their level of competence, it is necessary for prescribers to undertake an honest assessment of their current level of knowledge and skills and their ability to apply them in practice. This can be achieved through seeking the contribution and support of others (for example, colleagues, peers and/or managers) and reviewing the APS competency framework.

After a realistic assessment of knowledge, skills, and competence, it is necessary to identify learning needs and how these can be met. This will vary depending on:

• the role of the individual prescriber
• their scope of antimicrobial prescribing
• the needs of the organisation they work for

It is recommended that as learning and development continues, prescribers should revisit the APS competency framework regularly and continue self-assessment to monitor progress.

The APS competency framework can also be used by regulators, education providers and professional bodies to inform standards, guidance, and the development of training and educational materials where appropriate. Implementation of and assessment of practice against the APS competency framework can be used to demonstrate compliance with the code of practice in England.

APS competency framework

Domain 1. Person-centred care

Statement

All prescribers caring for patients with (suspected) infection must involve the patient/carer in shared decision making when agreeing and implementing a management plan to ensure patient-centred care.

1.1. Shares information with patients/carers about their infection management and antimicrobial treatment in a way that is understandable, respectful, encourages discussion, and promotes shared decision-making. This includes discussing with the patient/carers about what to do if their condition deteriorates (safety-netting advice) and making use of shared decision-making aids (for example, NICE, TARGET toolkit).

1.2. Manages patient/carers expectations or demands of antimicrobials and counsels about the need to use antimicrobials appropriately, including the risks and benefits of antimicrobial therapy.

1.3. Educates and supports patients/carers and others involved with care or service using evidence-based resources, such as the TARGET antibiotic checklist for community pharmacy and TARGET Treating your infection leaflets.

1.4. Supports the participation of patients/carers as integral partners when planning/delivering their care including where antimicrobials are not recommended, self-care advice, delayed or immediate antimicrobial prescribing, adverse effects and risk of AMR.

1.5. Counsels patients/carers about the risks of obtaining antimicrobials without a prescription including the risks of sharing antimicrobials prescribed for others or prescribed for animals.

1.6. Listens respectfully to the expressed needs of all parties in shaping and delivering care or services related to infection management and antimicrobial treatment.

1.7. Understands health inequalities associated with antimicrobial exposure and AMR.

1.8. Supports AMR public health campaigns such as World Antimicrobial Awareness Week, Keep Antibiotics Working, Antibiotic Guardian and e-Bug.

Domain 2. Infection prevention and control

Statement

All prescribers caring for patients with suspected infection must understand the core principles of infection prevention and control and use this knowledge appropriately to prevent the transmission of infection.

2.1. Understands how micro-organisms are transmitted in both community and hospital settings.

2.2. Understands and promotes the principles and practice of the prevention and control of infection.

2.3. Knows what an antimicrobial resistant organism is.

2.4. Knows how micro-organisms cause infections in humans and understands the differences between colonisation (for example, of venous leg ulceration or urinary catheters) and infection.

2.5. Understands that prescribing antimicrobials to patients colonised with MDR pathogens (for example, MDR gram negative pathogens in urine or gastrointestinal tract), will not eradicate the pathogens and should therefore not be used as a preventive measure to stop transmission of the resistant pathogens to others.

2.6. Knows the routes of transmission of infectious organisms (such as contact, droplet, airborne routes).

2.7. Recognises the characteristics of a susceptible host (for example immunocompromise).

2.8. Acts as a role model to healthcare workers and members of the public by adhering to infection prevention and control principles.

2.9. Understands how to use personal protective equipment (PPE) and when to apply to appropriate situations and applies standard precautions in healthcare environments.

2.10. Knows about the important micro-organisms that cause healthcare-associated infections and how they are transmitted and monitored. These would include:

• Methicillin-resistant Staphylococcus aureus (MRSA)
• Clostridioides difficile (C. difficile)
• Vancomycin-resistant Enterococcus (VRE)
• Extended Spectrum Beta-Lactamase (ESBL)-producers
• Carbapenemase-producing Enterobacterales (CPE)

2.11. Implements work practices that reduce risk of infection (such as taking appropriate immunisation or not coming to work when sick to ensure patient and other healthcare worker protection) and appreciates that healthcare workers have the accountability and obligation to follow infection control protocols as part of their contract of employment.

2.12. Understands the ‘Chain of Infection’ and the components required for infection transmission (such as presence of an organism, route of transmission of the organism from one person to another, a host who is susceptible to infection).

2.13. Understands the principles of why screening for colonisation (for example MRSA or CPE on admission to hospital) is important for reducing nosocomial spread.

2.14. Understands what is meant by contact precautions, droplet precautions and airborne precautions.

2.15. Applies appropriate policies/procedures and guidelines when collecting and handling specimens.

2.16. Implements a plan that is focused on limiting cross-infection and contamination to reduce healthcare associated infections and AMR in hospitals and community settings.

2.17. Recognises barriers to IPC protocols and knows how to raise concerns when required.

2.18. Understands the nature and classification of pathogenic micro-organisms (bacteria, viruses, and fungi) and knows which micro-organisms commonly cause infection in the UK.

2.19. Applies methods and strategies to prevent and control healthcare associated infections, including surgical site infections, catheter-associated bloodstream and urinary tract infections, healthcare-acquired pneumonia, gastroenteritis.

2.20. Identifies and manages the specific local factors responsible for increased risk of healthcare associated infections and AMR according to practice settings.

2.21. Understands the principles of infectious diseases epidemiology and the importance of surveillance for identifying new and emerging pathogenic microorganisms or changes in the prevalence of existing pathogens that impact on infection prevention and management.

2.22. Promotes the decontamination and sterilisation of equipment and patient areas in line with local policies and guidelines.

2.23. Knows about key national and international initiatives to promote effective infection prevention and control and address the threat of antimicrobial resistance.

2.24. Understands the structural differences between Gram-positive, Gram-negative, and atypical bacteria and their association with different human anatomical sites of infection.

2.25. Understands how current vaccines can benefit prescribing practices, including reducing the need for prescribing antimicrobials and decreasing resistant antimicrobial resistant strains, for example of S. pneumoniae.

2.26. Knows the relevant national and local immunisation programmes and the diseases for which vaccines are currently available and is aware of programmes for specific clinical risk groups, health and care staff and use of vaccination in outbreak situations.

2.27. Understands the general principles of immunisation (for example why multiple and/or booster doses are required, why intervals need to be observed between doses and why the influenza vaccine needs to be given annually).

2.28. Discusses clearly and confidently the risks and benefits of vaccination and addresses any concerns patients and/or parents/carers may have.

2.29. Understands and discusses current issues, controversies or misconceptions surrounding immunisation, and cultural sensitivities around refusal to take vaccines.

Domain 3. Antimicrobial resistance and antimicrobials

Statement

All prescribers caring for patients with suspected infection need to understand the core knowledge behind the action of antimicrobials and the concept of antimicrobial resistance; and use this knowledge to help prevent antimicrobial resistance.

3.1. Understands that the appropriate use of antimicrobials, including spectrum of activity and treatment duration, reduces the emergence of resistance.

3.2. Understands the major classes of antimicrobials, their mechanisms of action and their spectrum of antimicrobial activity in terms of Gram-positive, Gram-negative, anaerobic, and atypical bacteria and viruses, fungi and parasites.

3.3. Understands the concept of narrow-spectrum and broad-spectrum antimicrobials, the importance of using narrow spectrum antimicrobials where possible, and the contribution of broad-spectrum antimicrobials to antimicrobial resistance.

3.4. Understands clinical situations where broad-spectrum antimicrobials are warranted instead of narrow-spectrum.

3.5. Understands that appropriate use of antimicrobials reduces adverse effects (for example their disruptive effects on host normal flora or microbiota which may lead to, for example, opportunistic infection with C. difficile or Candida species, or inflammatory disorders such as inflammatory bowel disease).

3.6. Understands the burden of antimicrobial resistance to society, the importance of surveillance of epidemiological trends in resistance and the consequences of AMR for individual patient health outcomes.

3.7. Understands the major mechanisms of antimicrobial resistance and the implications for treatment of commonly encountered resistance profiles in terms of patient management (for example MRSA, VRE, ESBL, CPE).

3.8. Identifies factors contributing to AMR including inappropriate prescribing by healthcare workers and the sale of antimicrobials without prescription (for example over the counter in some parts of the world; online sales).

3.9. Understands local AMR epidemiology, resistance and susceptibility patterns and use of guidelines.

3.10. Understands the basic principles of susceptibility reports (antibiograms) and other reporting tools and their interpretation.

3.11. Recognises the challenge of diagnostic uncertainty for infection syndromes due to variation in pathogen epidemiology, unknown pathogen identification and the phenomenon of intrinsic and acquired resistance to antimicrobials.

3.12. Understands the principles of surveillance of AMR and antimicrobial use and the use of surveillance data.

3.13. Understands the mechanisms of antimicrobial resistance, including:

a. intrinsic or acquired resistance
b. the importance of selection advantages, for example the greater ability for some to colonise, to alter virulence, and how this can be an amplification process for antimicrobial resistance

3.14. Interprets and uses AMR surveillance data where appropriate.

3.15. Understands the concept of One Health where AMR is concerned and the inter-dependencies between human health, animal health, agriculture, food, and the environment.

3.16. Knows about the AWaRe categories of antibiotics from the WHO Essential Medicines List and the extent of national adoption of these within the UK.

Domain 4. Prescribing antimicrobials

Statement

All prescribers need to know about:

a. diagnosis and management of infections and use this knowledge to appropriately manage patients with infections, including the responsible
b. use of antimicrobial agents

Domain 4a. Diagnosis

4.1. Uses microbiological and other investigations to diagnose and monitor the response to treatment of infections and their complications, such as severe sepsis, for individual patient care and for public health purposes.

4.2. Knows not to initiate antibiotic treatment in the absence of bacterial infection.

4.3. Knows when not to prescribe antimicrobials, including the application of clinical decision aids, and when the use of alternatives, such as the removal of invasive devices, is appropriate (for example intravenous, or urinary catheters and incision and drainage of abscesses (source control)).

4.4. Requests and interprets relevant basic diagnostic tests in primary and secondary care that can guide antimicrobial therapy (for example microbiology, radiology, immunology, point-of-care tests).

4.5. Knows key features of and diagnostic criteria for specific infections (for example UTI, pneumonia, cellulitis) and the best narrow spectrum antibiotics to prescribe and length of antibiotic course in these scenarios.

4.6. Applies clinical decision aids (for example FeverPAIN) to target treatment to patients most likely to benefit from antimicrobials.

4.7. Applies relevant severity scoring tools such as NEWS2 or CURB-65 when initiating antimicrobial therapy and interprets results appropriately.

4.8. Interprets microbiology results/reports from the laboratory and knows the significance of preliminary pathogen identification (for example Gram stain) for selecting initial treatment and common methods of testing for antimicrobial resistance.

4.9. Reviews vital signs and inflammatory markers where appropriate (for example C-reactive protein, white cell count and procalcitonin) and other investigations when diagnosing and monitoring the response to treatment of infections and their complications.

4.10. Considers patient specific factors when diagnosing infections and choosing antimicrobials which may influence the choice of antimicrobial (for example immune function, allergy status, infection severity and risk of antimicrobial resistance – including previous exposure to antimicrobials or healthcare environments, relevant travel history or known colonisation or contact with resistant organisms).

Domain 4b. Use of antimicrobial agents

4.11. Prescribes antimicrobial agents appropriately for:

a. treatment of infections
b. prophylaxis to minimise the risk of infection only when necessary

4.12. Selects appropriate antimicrobial regimens paying due consideration to local and national guidance (for example from NICE and UKHSA and other specialist organisations producing antimicrobial guidance), including how, and where, to access this.

4.13. Selects appropriate antimicrobial regimens according to site of infection and anticipated pathogen groups and understands the concepts of empirical therapy and pathogen-directed therapy.

4.14. Understands the key elements of prescribing an antimicrobial, including:

• determining whether or not an antimicrobial is indicated; obtaining microbiological cultures or other relevant tests before commencing treatment as necessary
• the choice of agent
• the route of administration
• its pharmacokinetics and how this affects the choice of dosage regimen; how to monitor levels (therapeutic drug monitoring) and adjust doses (for example in obesity, the elderly or renal impairment)
• where to seek specialist advice
• decisions to switch agent (for example from intravenous to oral, narrower to broader spectrum or vice versa) based on microbiological results
• the duration of treatment
• when to consider review/stop dates

4.15. Uses local or national empirical therapy guidelines when prescribing empirical antimicrobial therapy and understands how local microbial/antimicrobial susceptibility patterns impact on the choice of empirical therapy.

4.16. Knows the common side-effects, including allergy, drug/food interactions, drug/disease interactions, less common but clinically significant side-effects and contraindications of the main classes of antimicrobials, the importance of monitoring for these, what to do when these are suspected, and methods to reduce likelihood of significant side effects such as screening and pharmacogenomic testing where available.

4.17. Knows that clinically significant drug-drug and drug-food interactions can cause antimicrobial toxicity or treatment failure and recognises antimicrobials that are potent inhibitors or inducers of drug metabolism.

4.18. Describes the principles of the pharmacokinetics and pharmacodynamics (PK-PD) of antimicrobials and the application of PK-PD principles for selection of dosing regimens, including for patients with organ dysfunction or at extremes of body weight.

4.19. Diagnoses and documents patient allergies to antimicrobials accurately.

4.20. Distinguishes between allergy and intolerance to antimicrobials appropriately.

4.21. Knows when to use a delayed (back-up) antimicrobial prescription and how to negotiate this with the patient.

4.22. Knows about trade and generic names, and the class, of a prescribed antimicrobial to avoid possible harm to patients in whom that antimicrobial is contra-indicated, for example due to hypersensitivity, coagulopathy, or organ impairment.

Domain 5. Antimicrobial stewardship principles

Statement

All prescribers must understand their role in and the importance of antimicrobial stewardship in promoting the appropriate use of antimicrobials to improve patient outcomes and reduce the emergence and transmission of antimicrobial resistance.

5.1. Recognises the importance of initiating prompt effective empirical antimicrobial treatment in patients with life-threatening infections (sepsis).

5.2. Documents the clinical indication, degree of diagnostic certainty, route, dosing regimen, duration, and review date of antimicrobials, within the prescription chart and/or in patients’ clinical records, as well as rationale for deviation from guidelines where relevant.

5.3. Avoids the unnecessary use of broad-spectrum antimicrobials.

5.4. Switches to the correct antimicrobial when susceptibility testing indicates resistance, or to a narrower spectrum or more cost-effective antimicrobial that is also compatible with the clinical presentation.

5.5. Understands why patients with self-limiting bacterial or viral infections are unlikely to benefit from antimicrobials.

5.6. Educates patients and their carers, the multidisciplinary healthcare team, and other supporting clinical staff when antimicrobials are and are not required and the importance of complying with the duration/frequency of administration of their prescribed antimicrobial and when to seek help.

5.7. Educates patients and their carers, the multidisciplinary healthcare team, and other supporting clinical staff about:

• IPC practices
• the natural history of common infections
• self-care (for example, with evidence-based interventions including analgesia, rest, and fluids)

5.8. Promotes best practice approaches to prescribing antimicrobials and ensures adherence to guidelines.

5.9. Understands the rationale and use of perioperative prophylactic antimicrobials to prevent surgical site infection, including the significance of timing of administration and indications for repeat dosing, and implements in practice where appropriate unless the duration of the operation/procedure is prolonged, there has been excessive blood loss or published national recommendations suggest otherwise.

5.10. Understands the importance of timely intravenous-to-oral switch and demonstrates the application of appropriate criteria to identify patients eligible for switch.

5.11. Conducts post-prescription review of antimicrobial therapy for hospital inpatients on all ward rounds 48 hours after initiation, appropriately selecting and documenting the prescribing decision in accordance with ARHAI guidance (SSTF).

5.12. Understands the principles of penicillin allergy de-labelling.

5.13. Recognises the immediate and long-term patient and ecological consequences of inappropriate antimicrobial prescription.

5.14. Accesses content of national evidence-based antimicrobial stewardship resources when necessary (for example, NICE guideline NG15, TARGET antibiotics toolkit and SSTF).

5.15. Prioritises the understanding of prescribing guidelines and practical application against market incentives to proliferate the prescription of antimicrobials.

5.16. Promotes capacity to search for reliable sources of unbiased/unconflicted information on the best use of antimicrobials.

Domain 6. Monitoring, learning, and interprofessional collaborative practice

Statement

All prescribers must collaborate with other health professionals when caring for patients with infection and demonstrate commitment to improving antimicrobial prescribing and stewardship within their scope of practice.

6.1. Understands why it is important to use locally agreed process measures of quality (for example compliance with guidance), along with outcomes and balancing measures, such as unintended adverse events or complications.

6.2. Develops trusting and collaborative relationships with patients/carers and other health/social care professionals when managing infections.

6.3. Establishes collaborative communication principles and actively listens to other professionals and patients/carers involved in the delivery of safe, effective antimicrobial therapy.

6.4. Uses the results of adverse event monitoring, laboratory susceptibility reports, antimicrobial prescribing audits and antimicrobial usage data to inform, in a timely manner, best antimicrobial prescribing practices, and so produces sustained improvements in the quality of patient care.

6.5. Communicates effectively to ensure common understanding of care decisions, including diagnostic certainty, treatment plan and risk of AMR or healthcare-associated infection.

6.6. Engages the views of others involved in antimicrobial treatment policy decisions, including championing best practice, and understands that it is a duty of care to co-operate with others more expert than oneself when such expertise is required.

6.7. Understands the roles, responsibilities, and competencies of other health professionals involved in the prescription, supply, and administration of antimicrobial therapy and that they should have a common understanding of antimicrobial treatment policy, the principles of antimicrobial stewardship and diagnostic stewardship; and their impact on safe and effective patient/client outcomes.

6.8. Engages regularly in team-based measurement of the quality and quantity of antimicrobial use and prescribing audits, and understands the significance of sharing results and good practice with all prescribers, as well as informing future antimicrobial surveillance and infection prevention and control measures.

6.9. Understands important human factors that can influence antimicrobial prescribing, including hierarchy and prescribing etiquette, and understands the implications for antimicrobial stewardship.

6.10. Understands basic principles of behaviour change in the context of prescribing antimicrobials, how prescribing antimicrobials can be influenced by factors other than clinical need and measures to prevent this, and demonstrates good prescribing habits.

6.11. Understands the common antimicrobial stewardship structures and processes deployed by healthcare organisations (for example clinical governance committees, monitoring quantity and quality of antibiotic prescribing; root cause analysis; education; audit and feedback; prescribing restrictions; laboratory reporting restrictions; drug formularies; guidelines and digital decision-support).

6.12. Engages in national antimicrobial stewardship initiatives aimed at supporting national policy and quality improvement, for example this may include Commissioning for Quality and Innovation (CQUIN) schemes in England.

Appendix 1. Update process

The APS competency framework was initially developed through an independent, multi-professional development group in 2013 by:

• Antimicrobial Resistance and Healthcare Associated Infection (ARHAI), now Antimicrobial Prescribing, Resistance and Healthcare Associated Infection (APRHAI)
• Public Health England (PHE), now UK Health Security Agency (UKHSA)

Antimicrobial prescribing and stewardship are fields that are constantly growing and developing; therefore, it is vital the competencies were reviewed and updated to ensure they reflect current guidance, and best practice recommendations to guide healthcare professionals appropriately.

For this update, a complete list of potential domains, statements, and descriptors for consideration was collated after review of the original APS competency framework and recognised alternative frameworks available. Resources used included:

• the RPS Competency Framework for all Prescribers
• draft curricula for pharmacy undergrad AMS and prescribing developed by NHS England Antimicrobial Prescribing and Medicines Optimisation Group
• consensus-based antimicrobial resistance and stewardship framework for undergraduate medical education (10)
• the Competency Framework for Health Workers’ Education and Training on Antimicrobial Resistance from WHO

A 2-step consensus gathering (Delphi) process was carried out involving 59 multidisciplinary professionals, including:

• 25 pharmacists
• 12 hospital doctors
• 6 general practitioners
• 5 nurses
• 4 academics
• 2 dentists
• 1 allied healthcare professional

These professionals were from a range of disciplines assessing the collated domains and statements of the APS competency framework at the first stage. The domains and corresponding statements were assessed for validity, and the descriptors ranked for essentialness via Likert scale.

Comments on the potential list of domains, statements, and descriptors were also received. The results were statistically analysed, and feedback incorporated. Greater than 75% of respondents felt the domains were valid without any further editing required; therefore, the decision was made to retain this format. Descriptors which reached consensus (>50% agreement = essential/absolutely essential) were included with the updated APS competency framework.

At stage 2, further feedback was received from a further 33 multidisciplinary professionals (including pharmacists, nurses, hospital doctors, epidemiologists, allied healthcare professionals); this was incorporated within the final version of the framework.

Appendix 2. Project contributors

Project leads were Tanya Miah (Chief Pharmaceutical Officer’s Clinical Fellow 2022 to 2023 at UKHSA) and Professor Diane Ashiru-Oredope (SSTF Lead, Lead Pharmacist for HCAI, AMR, AMU, Fungal and Sepsis Division at UKHSA).

This was in collaboration with Dr Kieran Hand (National Pharmacy and Prescribing Clinical Lead for AMR at NHS England).

We acknowledge multidisciplinary colleagues across the UK who provided feedback, including those listed and those whose names are not listed below:

ESPAUR Oversight Group, All Wales Antimicrobial Pharmacist Group, Jayne Walden, Kevin Frost, Sagaurav Shrestha, Tamsin Oswald, Stuart Bond, Eugen-Matthias Strehle, Heather Kennedy, Alicia Demirjian, Ana Phelps, Rashmeet Bhogal, Laura Whitney, Carol Philip, Ryan Hamilton, David Ferry, Dawn Elliot, Kimberley Sonnex, Kelly Alexander, Rebecca Hawkins, Scott Gillen, Naoko Arakawa, Andrew Bush, Katrina Barker, Trupti Patel, George Bugelli, Claire MacDonald, Antonella Tonna, Mark Brown, Kayleigh Lehal, Cristiano Serra, Caroline Burke, Meryl Davies, Nicholas Reid, Wendy Thompson, Sandra Martin, Jo McEwen, Yvonne Marie Dailey, Rose Gallagher, Melanie Wilson, Carolyn Chew-Graham, David Stephens, George Hales, Peter Lindsay, Tessa Lewis, Nastassya Chandra, Robin Allan, Veronica Chorro-Mari, Joanne Munns, Liz Craig, Rachel Medcalf, Laura Davidson, Corrine Ashton, Claire Donnelly, Cerys Lockett, Frances Garraghan, Carole Fry, Ravijyot Saggu, Naomi Fleming, Zena Uppal, Aneeka Chavda, Joseph Spencer-Jones, Douglas Izzard

References

1. Holmes, AH, and others. ‘Understanding the mechanisms and drivers of antimicrobial resistance’ The Lancet 387, pages 176-187 (2016)

2. Marston, HD, Dixon, DM, Knisely, JM, Palmore, TN and Fauci, AS. ‘Antimicrobial Resistance’ JAMA 316, pages 1193-1204 (2016)

3. Laxminarayan, R, and others. ‘Antibiotic resistance – the need for global solutions’ The Lancet Infectious Diseases 13, pages 1057-1098 (2013)

4. Majumder, MAA, and others. ‘Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health’ Infection and Drug Resistance 13, pages 4713-4738 (2020)

5. Doron, S and Davidson, LE. ‘Antimicrobial stewardship’. Mayo Clinic Proceedings 86, pages 1113-1123 (2011)

6. Davey, P, and others. ‘Interventions to improve antibiotic prescribing practices for hospital inpatients (updated protocol)’ Cochrane Database of Systematic Reviews (2017)

7. Schuts, EC, and others. ‘Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis’ The Lancet Infectious Diseases 16, pages 847-856 (2016)

8. MacDougall, C and Polk, RE ‘Antimicrobial Stewardship Programs in Health Care Systems’ Clinical Microbiology Reviews 18, pages 638-656 (2005)

9. Whiddet, S and Hollyforde, S. ‘A practical guide to competencies: how to enhance individual and organisational performance’ Chartered Institute of Personnel and Development, London (2003)

10. McMaster, D, and others. ‘Consensus-based antimicrobial resistance and stewardship competencies for UK undergraduate medical students’ JAC-Antimicrobial Resistance 2, dlaa096 (2020)