Strengthening Antimicrobial Stewardship Through Systems Design
Antimicrobial resistance (AMR) is one of the defining safety challenges of modern healthcare. While antimicrobial stewardship (AMS) programmes are now embedded across health systems, sustaining impact remains difficult. Prescribing decisions are made under time pressure, diagnostic uncertainty, competing targets, and organisational constraints. If stewardship is to be effective long term, it must be designed into the system, not layered onto it.
Current OxSTaR research focuses on strengthening AMS by applying systems thinking and human-centred design principles to real-world clinical environments. Two recent publications illustrate this approach.
A scoping review in The Lancet eClinicalMedicine titled “The latent system factors that influence antimicrobial use and governance in healthcare: A scoping review of high-income health systems” maps how systems approaches have been used to study and influence antimicrobial use across high-income settings. The review demonstrates that prescribing behaviour is shaped by far more than clinical knowledge or guideline awareness. Organisational governance structures, laboratory capacity, escalation pathways, performance metrics, and interprofessional dynamics all influence antimicrobial decision-making. Importantly, the review highlights persistent misalignment between strategic AMS goals at leadership level and the operational realities of frontline care. Addressing these gaps represents a significant opportunity for funders and health systems seeking durable improvements in antimicrobial use.
A complementary paper in The Lancet Infectious Diseases titled “Designing better systems to navigate the sepsis-antimicrobial stewardship tension” examines one of the most pressing stewardship challenges: the tension between rapid antibiotic administration for suspected sepsis and the need to avoid unnecessary antimicrobial exposure. Rather than framing this as a conflict between two competing priorities, the analysis demonstrates how system design can either amplify or attenuate this tension. Where governance structures, diagnostic pathways, and feedback mechanisms are aligned, high performance on both sepsis management and stewardship indicators is achievable. Where they are fragmented, clinicians face structural trade-offs that undermine AMS efforts.
Together, these publications reinforce a central message: sustainable antimicrobial stewardship requires system-level alignment. Effective AMS depends on integrating governance, measurement, workflow design, and human factors so that appropriate prescribing becomes the easiest and safest option.
“Support from the Ineos Oxford Institute (IOI) has enabled this work to move beyond describing prescribing patterns to articulating the organisational conditions that shape them. Within IOI, there is world-leading research focused on antimicrobial discovery, drug development, and pathogen genomics. OxSTaR’s contribution addresses a critical and comparatively underexplored dimension of the AMR challenge: how healthcare systems themselves influence antimicrobial use.” says Helen Higham, consultant anaesthetist, healthcare systems safety researcher, and director of the Oxford Simulation, Teaching, and Research Centre (OxSTaR).
While the world waits for new antibiotics, there is an urgent opportunity to optimise the systems in which existing agents are deployed. Future work will identify and analyse healthcare systems that demonstrate consistently strong AMS performance, making explicit the governance structures, cultural features, and operational designs that enable success. By translating these insights into actionable system-level interventions, this programme aims to
- Generate practical, near-term improvements in antimicrobial use
- Develop interventions that can help preserve current treatments
- Buy valuable time in the global response to antimicrobial resistance.