Improving Antimicrobial Stewardship and patient care in a Diabetic Foot Clinic
Laura Seddon – Stockport NHS Foundation Trust
Aim
The author aimed to reduce inappropriate antibiotic use within their treatment area in response to rising global concerns about antimicrobial resistance (AMR). AMR is recognised as a global public health emergency (1) and is projected to contribute to approximately 8.22 million deaths annually by 2050 (2). This is partly attributed to the increasing proportion of microbes potentially up to 20% developing resistance to antimicrobial agents, which is a significant concern for the author (3).
To address this issue, the author implemented an antimicrobial stewardship approach in line with recommendations from the World Health Organization (WHO) (1). These recommendations prompted the author to evaluate their own clinical practice and explore available tools to improve prescribing behaviours. While implementing these changes, the author also aimed to ensure that clinical outcomes and patient satisfaction were maintained. This will be demonstrated by monitoring the clinical progress of a patient with a diabetic foot ulcer under the author’s care.
Fig. 1
Method
To evaluate the effectiveness of the proposed antimicrobial stewardship (AMS) tool implementations, a six month audit was undertaken. The audit focused on antibiotic requests within the high risk diabetic foot clinic in which the author practised. This setting was selected due to the high volume of antibiotic requests received and their impact on clinical time, which could otherwise be used for direct patient care or education. The number of antibiotic rejections by the lead podiatrists was also monitored to assess whether improvements in prescribing practices reduced inappropriate requests.
The first tool implemented by the author was a Methicillin-resistant Staphylococcus aureus (MRSA) pathway (Fig. 1). This pathway incorporated assessment of clinical signs and symptoms of wound infection and provided guidance on appropriate antibiotic selection and duration. Antibiotic duration was specifically included in response to World Health Organization (WHO) guidance (2), which emphasises that duration is a critical component of prescribing that is not always adhered to in practice.
In addition, the pathway integrated adjunctive measures such as antimicrobial body washes, nasal decolonisation treatments, and antimicrobial soaks. It also recommended scheduling MRSA-positive patients at the end of clinic sessions to reduce transmission risk an approach the author had already implemented in practice but formalised within the pathway. Hand hygiene, a key component of AMS, was also embedded within the pathway. Alongside this, a patient pathway was followed to monitor wound progression, with consideration given to wound status and the use of appropriate dressings, including antimicrobial options available to the clinician. The second tool was an antibiotic request form which had to be completed prior to any antibiotic request (Fig. 2).
Fig. 2
Results
Patient: Left Heel. This patient presented with insulin controlled Type 2 Diabetes Mellitus with a suspected foreign body in the heel, which developed into an infected wound prior to removal. Medical history included ischaemic heart disease with previous NSTEMI and stage 3 chronic kidney disease. The patient was fully mobile and lived at home with a partner. Vascular assessment demonstrated no significant peripheral arterial disease, with triphasic waveforms noted; however, ankle-brachial pressure index readings were falsely elevated, consistent with arterial calcification. Following initial management in primary care and referral through district nursing services, the patient was assessed by a high-risk foot team and admitted for intravenous antibiotic therapy, optimisation of glycaemic control. Imaging excluded osteomyelitis and retained foreign body. A six week course of antibiotics (intravenous followed by oral therapy) was prescribed in accordance with microbiology guidance. Offloading strategies were implemented, limiting weight bearing to transfers only. Wound care included medical grade honey and regular specialist review until stabilisation, after which care was transitioned to community podiatry services. The wound achieved full epithelialisation within six months. Ongoing follow up focuses on prevention, including management of callus formation over the healed site.
11/2/25.
Surrounding tissue was warm and erythematous. The patient was prescribed intravenous co-amoxiclav
4/3/25.
Medical grade honey was continued to promote autolytic debridement and soften slough. The wound measured 100 mm × 80 mm.
26/3/25.
Medical-grade honey dressings were continued to reduce odour and support debridement. The patient was prescribed oral amoxicillin
23/5/25
continued with off loading and current dressing regime
These results demonstrate a positive impact on clinical practice, with antibiotic requests decreasing from 45 in April to 16 in September following implementation of the pathway and request form (Fig. 1). Increased training and awareness of antimicrobial resistance further contributed to a reduction in inappropriate requests and antibiotic rejections.
Discussion
The implementation of antimicrobial stewardship (AMS) strategies within the high-risk diabetic foot clinic reflects a proactive response to the growing global threat of Antimicrobial Resistance, which has been identified by the World Health Organization as a major public health concern. The author’s approach introducing a structured MRSA pathway and mandatory antibiotic request form demonstrates alignment with international guidance aimed at optimising antimicrobial prescribing while safeguarding clinical outcomes.
A key strength of this initiative is its focus on behavioural change in prescribing practices. The introduction of a formalised pathway encouraged clinicians to justify antibiotic use based on clinical indicators rather than habitual or precautionary prescribing. This is particularly relevant in high-risk diabetic foot settings, where infection is common and diagnostic uncertainty may lead to overprescribing. By incorporating antibiotic duration into the pathway, the author addressed a frequently overlooked aspect of prescribing, supporting WHO recommendations that inappropriate duration contributes significantly to resistance. However, while the reduction in inappropriate antibiotic requests is a desirable outcome, it is important to critically consider whether stricter controls could inadvertently delay necessary treatment. In complex cases such as diabetic foot infections, early antibiotic intervention can be crucial in preventing deterioration, including progression to osteomyelitis or amputation. Therefore, an overly rigid AMS framework may increase risk under treatment if clinical judgement is constrained. The effectiveness of such tools depends heavily on clinician engagement and the flexibility to treat patients while acting in the patient's best interest.
The patient case presented provides valuable insight into the practical application of AMS principles. Despite the emphasis on reducing antibiotic use, this patient required multiple antibiotics, highlighting that stewardship does not equate to restriction alone but rather optimisation. The successful outcome complete epithelialisation within six months suggests that appropriate antibiotic use, guided by microbiology input, remains essential in managing complex infections. This supports the argument that AMS should prioritise appropriate rather than reduced prescribing. Additionally, the integration of adjunctive measures such as decolonisation protocols, wound care strategies, and infection control practices strengthens the overall approach. These non-antibiotic interventions are often underutilised but play a critical role in reducing infection burden and transmission. The formalisation of practices already being carried out, such as scheduling MRSA patients at the end of clinics, demonstrates how standardisation can improve consistency and accountability.
On the other hand, the audit’s focus on quantitative measures such as the number of antibiotic requests and rejections may not fully capture the complexity of clinical decision making or patient centred outcomes. Patient expectations can influence prescribing behaviour, and reduced antibiotic use may conflict with perceived quality of care. Future evaluations could benefit from incorporating patient reported outcomes to provide a more comprehensive assessment of AMS impact. While intended to improve prescribing quality, additional administrative tasks may contribute to clinician workload and reduce time available for direct patient care. This creates a tension between governance and efficiency, suggesting that AMS tools must be carefully designed to integrate seamlessly into clinical workflows. This is why the author collected data to show the time saved with antibiotic requests reducing from 45 – 16.
Conclusion and References
This evidence submission demonstrates that the implementation of antimicrobial stewardship (AMS) strategies within a high-risk diabetic foot clinic can positively influence prescribing behaviours without compromising patient outcomes. The introduction of a structured MRSA pathway and mandatory antibiotic request form contributed to a clear reduction in antibiotic requests and inappropriate prescribing, supporting alignment with guidance from the World Health Organization on optimising antimicrobial use.
Importantly, the findings reinforce that effective AMS is not solely about reducing antibiotic use, but ensuring appropriate, evidence based prescribing. The presented patient case highlights this balance, where multiple correct antibiotics was clinically justified and contributed to successful wound healing. This underscores the need for stewardship approaches to remain flexible and guided by clinical judgement, particularly in complex cases such as diabetic foot infections.
The initiative also highlights the value of integrating adjunctive non-antibiotic interventions, multidisciplinary collaboration, and standardised clinical pathways to support holistic patient care.
Overall, this work supports the role of structured AMS tools in improving prescribing practices while maintaining quality of care. Future improvements should focus on enhancing clinician engagement, incorporating patient perspectives, and ensuring that stewardship interventions are both effective and sustainable within routine clinical practice.
References
- World Health Organization. Promoting antimicrobial stewardship to tackle antimicrobial resistance
- GRAM Project (2024) – Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050, The Lancet
- Naghavi M et al. (2024). Global burden of antimicrobial resistance