Antimicrobial Stewardship in Care Homes: A Practical Guide

Antibiotic resistance rarely makes headlines in the way outbreaks do, but it's arguably the slower-moving, more consequential infection control challenge facing care homes. Every unnecessary or inappropriate course of antibiotics contributes to resistant bacteria becoming more common — and care home residents, who are older, often have multiple comorbidities, and experience frequent antibiotic exposure, are disproportionately affected when treatments stop working.

What Antimicrobial Stewardship Actually Means

Antimicrobial stewardship is the coordinated effort to ensure antibiotics are prescribed only when genuinely needed, at the right dose, for the right duration, and using the narrowest effective antibiotic rather than defaulting to broad-spectrum options. In a care home context, this isn't primarily a prescribing decision staff make directly — that sits with GPs and pharmacists — but care staff play a critical supporting role in providing the accurate clinical information that makes appropriate prescribing possible in the first place.

Why Care Homes Are a Particular Focus

Urinary tract infections illustrate the problem well. Asymptomatic bacteriuria — bacteria present in urine without any symptoms of infection — is extremely common in older adults and doesn't require antibiotic treatment, yet it's frequently over-diagnosed and over-treated in care settings, often because cloudy or strong-smelling urine is mistakenly treated as sufficient evidence of infection on its own. National guidance is clear that a urine dipstick alone, without accompanying symptoms like new confusion, fever, or urinary pain, isn't a reliable basis for starting antibiotics in older adults — but this message doesn't always filter down consistently to frontline practice.

The Care Staff Role in Supporting Appropriate Prescribing

When a GP or out-of-hours service is deciding whether antibiotics are needed, they're relying heavily on the information care staff provide, often over the phone without having examined the resident themselves. Staff who can describe specific, meaningful clinical signs — new confusion, a raised temperature, reduced oral intake, specific pain — give a prescriber far better information to work with than a general "not themselves" or "urine looks odd" description. Structured tools like the RESTORE2 or NEWS2 deteriorating-resident recognition frameworks help staff capture and communicate this information consistently, supporting more accurate decisions about whether antibiotics are actually indicated.

Completing the Full Course

Beyond avoiding unnecessary prescriptions, appropriate use of antibiotics that are genuinely needed matters too — ensuring the full prescribed course is completed even once a resident's symptoms improve, since stopping early can allow surviving bacteria to develop resistance. Care staff administering medicines have an important role in this, both in ensuring doses aren't missed and in flagging to the prescriber, rather than independently stopping treatment, if a resident experiences side effects that make continuing difficult.

Watch and Wait Approaches

For some infections, particularly where a resident is otherwise stable, a "watch and wait" or delayed-prescription approach — monitoring closely for a defined period before starting antibiotics, rather than treating immediately at the first sign of possible infection — is increasingly recommended. This requires care staff to be comfortable with a period of active monitoring without antibiotic treatment, which can feel counterintuitive if the instinct is to seek treatment as quickly as possible, but is genuinely part of appropriate, evidence-based care rather than a delay in care.

Building Stewardship Into Home Culture

Homes that engage well with antimicrobial stewardship typically have a designated link person — often a senior nurse — who stays current with local antimicrobial guidelines, supports staff in gathering the right clinical information before contacting a prescriber, and reviews infection and prescribing patterns periodically to spot any concerning trends, such as unusually frequent antibiotic use for a particular symptom or resident group.

Local Antimicrobial Guidelines

Antimicrobial prescribing guidance varies somewhat by local health area, reflecting local resistance patterns and formulary decisions, so care homes should know how to access their local Integrated Care Board's current antimicrobial guidelines rather than relying solely on generic national guidance. Keeping a copy of the relevant local guideline accessible to nursing staff, and reviewing it when updated, supports more informed conversations with prescribers when infection is suspected.

Frequently Asked Questions

Should cloudy or strong-smelling urine alone lead to antibiotic treatment?
No. Without accompanying symptoms like new confusion, fever, or urinary pain, this alone isn't considered reliable evidence of infection requiring antibiotics in older adults.

What's the care staff role in antimicrobial stewardship?
Providing accurate, specific clinical information to prescribers, supporting full completion of prescribed courses, and flagging concerns to the prescriber rather than independently adjusting treatment.

What is a "watch and wait" approach to suspected infection?
Monitoring a resident closely for a defined period before starting antibiotics, used where appropriate as part of evidence-based, judicious antibiotic use rather than immediate treatment.

Good stewardship practice builds on the structured recognition tools covered in our guide to RESTORE2 and NEWS2 deteriorating resident recognition, and connects to wider infection control practice in hand hygiene training. For structured training on infection prevention and control, see Learnsignal's CPD courses.