Antimicrobial Stewardship Moves Beyond Hospitals Into Communities and Farms

Antimicrobial resistance (AMR) remains one of the most pressing public health threats of the twenty-first century, and a new collection of studies argues that the fight against it must move decisively beyond hospital wards and into the places where most antimicrobial exposure actually happens: primary care clinics, pharmacies, households, and farms. An editorial published in Frontiers in Antibiotics by Elmien Bronkhorst of Sefako Makgatho Health Sciences University in Pretoria, South Africa, synthesizes a Research Topic on innovations and impacts of antimicrobial stewardship in primary care and proximity settings, drawing together evidence from Serbia, sub-Saharan Africa, and beyond to sketch a blueprint for community-centered stewardship.

The central premise of the collection is that conventional stewardship, which has traditionally focused on optimizing antibiotic prescribing within hospital systems, captures only part of the problem. Most human and animal exposure to antimicrobials occurs in community and proximity settings, where prescribing decisions, self-medication, agricultural practices, and regulatory enforcement all interact. The editorial argues that individualized, community-based approaches, including public engagement, education on self-care, inclusion of veterinary sectors, and attention to broader societal determinants of resistance, are now recognized as essential components of any credible response to AMR.

One of the most provocative contributions, a review by Kiggundu and colleagues, explores the integration of self-care strategies into AMR containment efforts. The authors broaden the traditional stewardship paradigm by repositioning individuals from passive recipients of prescriptions to active participants in infection prevention and antimicrobial decision-making. Through targeted AMR education, self-care interventions have the potential to improve health literacy, enable earlier detection of infections, and reduce unnecessary healthcare utilization. The mechanisms they describe include rapid diagnostic self-testing, guided self-treatment, self-monitoring, and supported self-management, with digital health technologies and community health systems emerging as key enablers of responsible self-care.

However, the review is careful to note that self-care is not risk-free. Benefits may be undermined by limited access to reliable information, diagnostic uncertainty, and the potential for inappropriate antibiotic use when patients act without professional oversight. The authors therefore frame community empowerment as a future direction for stewardship that must be accompanied by adequate safeguards, regulation, education, and professional support. This tension between expanding access to antimicrobial decision-making and preventing misuse runs throughout the collection and reflects a broader debate in global health about how to decentralize care safely.

The importance of sustained public engagement is demonstrated by Bajčetic and colleagues, who describe one of Europe’s most successful national antibiotic awareness initiatives. Serbia’s multisectoral educational campaign, known as Careful with Antibiotics, combined public education, professional training, guideline development, and regulatory reforms into a single coordinated program. The results show one of the most substantial and sustained reductions in systemic antibiotic prescriptions in Europe, with particularly encouraging declines in antibiotic prescribing for common respiratory tract conditions that have historically driven inappropriate use. The Serbian experience suggests that stewardship is most effective when it extends beyond clinical practice into public communication, professional education, and health policy, offering a scalable model for countries seeking sustainable interventions in primary care.

The challenges of stewardship beyond human healthcare are highlighted by Mugyabuso and colleagues, whose study applies a One Health perspective to cattle keeping. Their findings reveal low awareness of antimicrobial use, residues, and resistance among cattle keepers, accompanied by poor stewardship practices and significant regulatory weaknesses. The widespread availability of non-prescription antimicrobials, reliance on empirical treatment decisions, and limited AMR knowledge among some animal health stakeholders represent serious threats to stewardship efforts. Crucially, the study identifies education and awareness as modifiable factors strongly associated with responsible antimicrobial attitudes, suggesting that targeted training in agricultural communities could yield measurable gains. The implication is stark: efforts to improve prescribing in human healthcare may achieve only limited success if parallel challenges in animal health remain unaddressed.

While the first three contributions focus on strengthening stewardship interventions, a perspective by Amábile-Cuevas presents a thought-provoking challenge to conventional AMS assumptions. The author argues that the relationship between antibiotic consumption and resistance is more complex than traditionally acknowledged, with socioeconomic, environmental, and biological factors potentially influencing resistance patterns as strongly as, or more than, clinical antibiotic use. This argument does not dismiss the value of stewardship. Stewardship programs undoubtedly improve patient safety, reduce unnecessary antimicrobial exposure, and lower healthcare costs. But expecting AMS alone to reverse resistance trends may be unrealistic given broader drivers such as agricultural antimicrobial use, urbanization, sanitation challenges, and the dissemination of mobile genetic elements that carry resistance genes between bacterial populations.

This reframing has practical consequences for how stewardship programs are designed and evaluated. If resistance dynamics are shaped as much by plumbing, poverty, and livestock husbandry as by prescription volumes, then stewardship must be embedded within wider health systems and incorporate societal approaches rather than operating as a narrowly clinical intervention. The editorial takes this lesson seriously, arguing that the complexity of AMR demands strategies that address behavioral, environmental, regulatory, and socioeconomic determinants alongside prescribing behavior itself.

Taken together, the contributions in the collection highlight several recurring themes. First, AMS is increasingly moving beyond hospitals into communities, households, pharmacies, and agricultural settings. Second, effective stewardship requires engagement of multiple stakeholders, including patients, caregivers, pharmacists, veterinarians, policymakers, and public health practitioners. Third, education remains a cornerstone of stewardship, whether directed at self-carers, parents, healthcare professionals, or livestock keepers. These convergent findings suggest that the future of AMS in primary care and proximity settings depends on balancing innovation with evidence-based implementation, ensuring that self-care technologies, digital health tools, public awareness campaigns, and One Health interventions are deployed with appropriate safeguards and continuous evaluation.

As AMR continues to threaten global health gains, the editorial concludes that effective stewardship must be collaborative, context-specific, and inclusive. By bringing antimicrobial stewardship closer to the communities where antimicrobials are actually used, primary care and proximity settings are poised to become critical frontiers in the global response to AMR. The collection demonstrates that meaningful progress is achievable when stewardship is viewed not merely as a clinical intervention, but as a shared societal responsibility spanning clinics, homes, and farms alike.

Subject of Research: Antimicrobial stewardship innovations in primary care and community settings to combat antimicrobial resistance

Article Title: Editorial: Innovations and impacts of antimicrobial stewardship in primary care and proximity settings

Article References: Bronkhorst, E. (2026). Editorial: Innovations and impacts of antimicrobial stewardship in primary care and proximity settings. Frontiers in Antibiotics, 5, Article 1995353. https://doi.org/10.3389/frabi.2026.1995353

Image Credits: AI Generated

DOI: 10.3389/frabi.2026.1995353

Keywords: antimicrobial resistance, antimicrobial stewardship, primary care, self-care, One Health, public health, antibiotic prescribing, community health, veterinary antimicrobials, digital health, AMR education, health policy