Exploring UK medical schools’ perception and intent for teaching on antimicrobial resistance and stewardship

Abstract

Background

Antimicrobial resistance (AMR) is a key global public health threat. Developing healthcare worker awareness and knowledge in AMR and antimicrobial stewardship (AMS) are UK national action plan targets. Competency frameworks have been developed to support improved undergraduate teaching, but their uptake is unclear.

Methods

A targeted survey was sent to all UK medical schools to determine curriculum learning objectives (LOs) on AMR/AMS and distribution of teaching opportunities across courses. Replies were mapped to the six McMaster competency framework domains to identify areas of strength and potential gaps in undergraduate teaching models.

Results

Replies were received from 50/52 (96.2%) medical schools. AMR/AMS teaching through dedicated teaching sessions was offered by 32/50 (64.0%), whereas 11/50 (22.0%) had fully integrated courses and 7/50 (14.0%) were unable to identify any LOs. Data on dedicated teaching provision (mean 7.7 h/course, IQR 3.0–10.5) were provided by 32/50 (64.0%). Evidence for mapping to the McMaster competencies was highly variable, ranging from 1/50 (2.0%) to 35/50 (70.0%) across the six key domains. Where identified, mapping to knowledge-based competencies was observed to be significantly greater than to practical-based competencies (OR 3.2, 95% CI 2.5–4.1, P < 0.0001). Ten of 50 (20.0%) highlighted learning opportunities in clinical years were opportunistic, variable, indirect or incidental.

Conclusions

Current approaches to UK undergraduate AMR/AMS medical education appear limited, with greater focus on knowledge-based competencies and less focus on practical skills. Reliance on opportunistic teaching in clinical years presents challenges for programme assurance and impact assessment. Minimizing unwanted variability in medical school teaching and learning in AMR/AMS should be pursued, and inclusion in the UK Medical Licensing Assessment content map may provide such an opportunity.

Introduction

Antimicrobial resistance (AMR) is one of the most significant current global public health risks.¹ Education and awareness-building among both patients and healthcare staff are seen as vital elements of global health strategies to address AMR.² The evolving nature of AMR and the continued emergence of novel diagnostics, mitigation measures and therapeutics present challenges to educators, however, amid a need to support adapting roles and stay up to date.³ Undergraduate education also presents an important opportunity to establish antimicrobial stewardship (AMS) within early development of prescribing practices.

In the UK, the 2024–2029 national action plan for AMR has set a target of 2029 to improve knowledge among healthcare professionals.⁴ The plan also commits to increase the scope, and require the completion of, AMS and infection prevention and control (IPC) training across the healthcare workforce, including students.⁴ To support early training efforts, frameworks for improving healthcare worker training have been developed, and the UK Health Security Agency continues to support education and awareness campaigns.^5,6 Regarding medical student training, a 2018 systematic review concluded that considerable evidence existed for insufficient prescribing competencies at graduation, including confidence and knowledge around antimicrobial use, and cited a greater need for consensus on required competencies.⁷ In 2020, McMaster and colleagues,⁸ representing 25 UK medical schools, then provided considerable support for addressing this gap by developing a consensus framework for AMR and AMS teaching during undergraduate medical education. This framework broadly reflects the desired competencies from international education frameworks provided by the WHO.⁹

Despite such efforts, however, the uptake of curricula or recommended competencies and their impact have been unclear.² Findings from the 2025 independent UK National Audit Office (NAO) Report on AMR have highlighted concerns with an ongoing lack of awareness among healthcare professionals.¹⁰ AMR is a complex issue that requires strong foundations in understanding to engage effectively with effective AMS, safe prescribing and IPC. Considering the NAO report and in keeping with the aims of the current National Action Plan, we examined current UK medical school approaches for delivering on AMR and AMS training to identify and share examples of good practice and inform any potential education gaps.

Methods

A request was sent to all 52 medical schools in the UK to detail their current approach to delivering AMR and AMS teaching across their undergraduate curricula. The request comprised three questions including whether, within their individual medical school curriculum, (i) AMR and/or AMS featured with specific learning outcomes, (ii) if so, what specific learning outcomes featured, and (iii) how much time was allocated, broken down by year of teaching, for AMR and/or AMS? The aims were to determine medical schools’ own perceptions of teaching on AMR and AMS and describe areas of strength and potential gaps in their delivery across UK undergraduate education.

Exploring time available and approaches for AMR/AMS teaching

Time apportioned to teaching AMR/AMS content within medical school curricula was used as a basic measure for comparing how approaches to delivery of learning outcomes (LOs) differed across and between courses. This included determining how teaching was weighted between preclinical basic science and clinical phases of the course. Time was reported in hours and assumed to represent intended baseline material that was uniformly provided across each medical school student cohort.

Mapping of learning outcomes

LOs were extracted from replies and mapped to the McMaster 2020 consensus framework for undergraduate medical education.⁸ Representatives from 25/47 (53.2%) active UK medical schools were involved in the development of this framework. Since then, five new medical schools have opened. This framework has also helped inform wider UK competency frameworks, including an indicative curriculum for training pharmacists and government guidance on antimicrobial prescribing and stewardship competency frameworks for healthcare workers.^6,11 It was felt that its UK undergraduate focus and its use in informing wider UK curricula offered a fair and relevant comparator.⁸ Where available, extracted LOs for each individual medical school were coded as either specific (e.g. ‘prescribe antibiotics used perioperatively, as prophylaxis, and for common infections in a simulated setting’) or non-specific (e.g. ‘describe the concept of AMS’). In the first instance, extracted replies were considered collectively for each medical school and used to map that school’s collective LOs against each of the six McMaster domain competency statements, including (i) infection prevention and control, (ii) antimicrobials and AMR, (iii) antimicrobial prescribing and stewardship, (iv) vaccine uptake, (v) person-centred care and (vi) interprofessional collaborative practice.⁸ Replies were reviewed by two investigators independently (Z.L.L. and S.J.C.P.) and broadly mapped to competency statements. If in doubt, authors erred on the side of positive mapping for these statements, acknowledging likely variation in approaches and description of covered material across sites.

Following mapping to competency statements, extracted replies were mapped to individual descriptors within each domain. The framework comprises 58 individual descriptors. Six were removed (5.1 to 5.4, 6.4, 6.5)⁸ as they contained no direct reference to AMR or AMS and were considered core aspects of skills required by General Medical Council (GMC) Good Medical Practice guidance.¹² To gain more insight on focus of teaching and to identify any comparative gaps, each of the remaining 50 descriptors were designated as either primarily knowledge-based (e.g. ‘describe the spectrum of activity for commonly prescribed antibiotics’) or practical skill-based (e.g. ‘describe and demonstrate switching to the correct antimicrobial when susceptibility testing indicates resistance, or to a cheaper or more cost-effective antimicrobial that is also compatible with the clinical presentation’). In addition to the six domains, descriptors aimed at developing key practical skills including diagnostic use and stewardship or use of policy and guidance were also considered separately.

Statistical analysis

Descriptive statistics were used to summarize LO availability, teaching hours and mapping frequencies. The ORs with 95% CIs were calculated to compare the likelihood of knowledge-based versus practical skill-based outcomes. Significance was set at P < 0.05.

Ethics

Data were collected and shared in response to Freedom of Information requests to public bodies and organizations under the Freedom of Information Act 2000 for England, Wales and Northern Ireland and the Freedom of Information (Scotland) Act 2002.

Results

Of the 52 UK medical schools surveyed, data were provided by 50/52 (96.2%). Two did not reply to the query. For each reply, an answer was provided for all three questions.

Approaches to AMR/AMS teaching delivery across universities

Approaches for delivering AMR and AMS teaching varied considerably across medical schools. The majority (32/50, 64.0%) offered dedicated teaching sessions in the form of lectures, tutorials or ‘masterclasses’, of which 18/32 (56.3%) also reported expectation of students gaining additional experience during clinical placements. In contrast, 11/50 (22.0%) described AMR and AMS teaching as fully integrated concepts within their courses, being introduced and revisited as a part of other sessions or delivered via encounters during clinical placements. For the remaining 7/50 (14.0%), no data on teaching delivery were identifiable. One school declined to comment on teaching provision as it would take >20 h to identify, whereas the remaining six confirmed dedicated teaching either did ‘not exist’ or curricula were not yet validated or mapped.

In addition to lectures and tutorials, examples of delivered teaching sessions also included simulated practical sessions including for ‘prescribing antibiotics used perioperatively, as prophylaxis, and for common infections’, ‘practicals on diagnostic microbiology and virology’, ‘virtual AMS ward rounds’, ‘prescribing antibiotics…utilising local and national guidelines’, and ‘documentation of decision-making’. In other settings, interprofessional teaching was delivered in collaboration with MSc Pharmacy students or learning opportunities augmented by complementary twilight lecture series.

In 10/50 (20.0%) cases there was recognition that approaches to teaching would mean experiences by medical students would invariably differ. Example comments included that ‘learning may be incidental’, ‘indirect’, ‘opportunistic’ or ‘ad hoc’, that ‘teaching opportunities vary’, ‘since there are no dedicated modules or sessions for these topics…necessarily vary over time and between cohorts’ or that duration of teaching on these topics was ‘down to the teacher’s discretion.’ In one case, reasoning was notably provided for an absence of dedicated teaching on these topics as the curriculum must consider the content of the Medical Licensing Assessment (MLA).

Time dedicated to AMR/AMS teaching

The apportioning of time available to deliver teaching on AMR and AMS also varied considerably. Among those medical schools that opted to deliver teaching in dedicated sessions, estimated teaching across a 5 year course ranged between 0.5 and 21.5 total hours (mean 7.7 h/course, IQR 3.0–10.5). One school estimated 50 related learning hours across the 5 years (including online learning resources and clinical placements) but it was unclear how much of this represented taught sessions. Among reporting of the higher durations, it was difficult to determine whether they represented AMR/AMS teaching specifically or also included general pharmacology or prescribing teaching. Most of this teaching was delivered in the preclinical phase, compared with the clinical phases of the curriculum, in keeping with respondents noting a shift to variable/ad hoc AMR/AMS teaching opportunities in the latter period (Figure 1).

Figure 1.

Dedicated time available for teaching antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) as a core topic across UK medical schools, 2025. Fifty medical schools described time spent delivering AMR/AMS-specific teaching. Thirty-one of 50 (62.0%) of schools reported a distribution of scheduled teaching hours on AMR and/or AMS and are represented graphically, 19/50 (38.0%) reported a total number of estimated hours but without further breakdown (n = 2), or reported integrated teaching approaches, or were unable to determine teaching delivered and are not represented graphically. Boxes represent data median and interquartile ranges with blue circles representing individual outliers.

Learning outcomes

LOs for AMR and/or AMS were identified by 42/50 (84.0%) medical schools, with 26/50 (52.0%) identifying specific LOs compared with 16/50 (32.0%) that identified only non-specific LOs. Examples of non-specific LOs included limited requirements to ‘describe the concept’ of AMR or AMS without further detail. Of the 8/50 (16.0%) that reported no identifiable LOs, these included those that were yet to map their full curriculum and also those whose approach to framing of AMR/AMS teaching included ‘AMR and AMS are introduced as concepts…do not have specific learning objectives.’ Contribution to the development of the McMaster curriculum was not correlated with identification of LOs, or where available, whether they were specific or non-specific in their nature (P = 0.77). Only 1 of 50 (2.0%) medical schools appeared to have adopted the McMaster curriculum.⁸

Mapping of LOs to objectives identified in the McMaster curriculum was highly variable (Figure 2a). Medical school LOs satisfying the overarching competency statement for each domain were most often identified for AMR (40/50, 80.0%) and antimicrobial prescribing and stewardship (30/50, 60.0%) (Figure 2a). Mapping of AMR/AMS-related LOs to the IPC domain was also evident in 15/50 (30.0%) and to the vaccine uptake domain in 9/50 (18.0%) of cases. There was limited evidence of clear mapping to the statements for interprofessional collaborative practice (4/50, 8.0%) or patient-centred care (1/50, 2.0%) domains from an AMR/AMS specific perspective. For the latter, there was also evidence (1/50, 2.0%) of recognizing the ‘role of the pharmacist…in advising patients and doctors on the use of medicines’ but without mention of the doctor’s role.

Figure 2.

Distribution of learning objectives for antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) teaching across domains for UK medical schools, 2025. Data compiled from the replies of 50/52 (96.2%) medical schools. No reply was received from the remaining two schools. (a) Mapping of identified learning objectives to the six domain competency statements of the McMaster framework. (b) Evidence for mapping of learning objectives to McMaster competencies that focus on diagnostic stewardship or use of policy guidance. The domain competency statements include: (i) Infection prevention and control (IPC): All newly qualified doctors must understand the core knowledge underpinning infection prevention and control and use this knowledge appropriately to prevent the spread of infection. (ii) AMR: All newly qualified doctors need to understand the core knowledge underpinning the action of antibiotics and use this knowledge to help prevent antimicrobial resistance. (iii) Prescribing/AMS: All newly qualified doctors need to demonstrate knowledge in how infections are diagnosed and managed and use this knowledge appropriately to manage patients with infections including the appropriate use of antimicrobial agents. (iv) Vaccines: All newly qualified doctors need to demonstrate knowledge in the importance of vaccines in reducing antimicrobial resistance and use this knowledge appropriately to promote vaccination. (v) Person-centred care: All newly qualified doctors must seek out, integrate and value as a partner the input and engagement of the patient/carer in designing and implementing care. (vi) Interprofessional practice: All newly qualified doctors need to understand how different professions collaborate in relation to how they contribute to AMS.

Within each domain, there was significant evidence of greater mapping to knowledge-based LOs than to practical-skill LOs related to AMR/AMS (OR 3.2, 95% CI 2.5–4.1, P < 0.0001). Mapping was most frequently found to LOs describing the spectrum of activity for commonly prescribed antimicrobial agents (30/50, 60.0%), awareness of factors contributing to AMR including inappropriate prescribing (23/50, 46.0%) and describing key features of common infections and the best approach for prescribing narrow-spectrum antibiotics where appropriate (23/50, 46.0%). Mapping to LOs targeting diagnostic stewardship and interpretation were evident in 21/50 (42.0%) cases, and those targeting use of policy/guidelines to support antimicrobial prescribing in 16/50 (32.0%) of cases (Figure 2b).

Discussion

These data evidence how AMR and AMS teaching across UK undergraduate medical education is highly variable in approach, scope and volume. We identified a range of methods used for teaching about this major public health risk. There was, however, a paucity of evidence for providing a strong foundation for confident engagement with AMS by the time of graduation.

Teaching methods remain mixed, difficult to measure and with unclear impact

Approaches to teaching remain mixed, with some schools opting to provide dedicated teaching sessions and others integrated curricula, where the aim is to avoid compartmentalization of medical education. Regardless of method, there was evidence of greater focus on developing basic science knowledge, particularly around mechanisms of resistance, but limited evidence of developing the practical skills required to manage infections complicated by AMR or engage confidently in AMS practices. LOs in clinical settings, where students may build on preclinical knowledge to develop these practical skills, were recognized by several institutions as difficult to measure and likely variable across their student cohorts. Meanwhile, studies have previously shown that medical students would like more training in safe antimicrobial prescribing,⁷ a desire for AMS/AMR education that continues into their early postgraduate clinical career.¹³ This is particularly important given observations from a scoping review that postgraduate exposure to antimicrobial decision making by senior colleagues can be opaque, lacking in feedback, and deter trainees from suggesting stopping or changing therapies.¹⁴ It is unlikely that the often-shared exposures would differ significantly for students, and with the NAO report highlighting concerns in healthcare worker awareness, consideration may need to be given on whether current approaches in the UK are measurable or having sufficient impact.^7,10,13

Relying on ad hoc learning opportunities can present challenges for qualifying the quality and accuracy of learning. Alternative options are apparent, however, with some programmes in this study opting to deliver targeted interprofessional teaching in the final year alongside pharmacy students, for example.

Alignment to national requirements and specific targets may improve quality and impact assessment

Recent reports of novel undergraduate electives focusing on AMS have shown increased perception of competency among medical students, although the authors highlight scalability concerns unless integrated into the curriculum.¹⁵ This may not be straightforward, however, with our data showing even when medical schools are involved in developing competency frameworks, it does not necessarily lead to local implementation. Greater integration of AMR and AMS competencies across medical curricula in the UK is likely to be limited unless reflected in national requirements. Direct reference to AMR, AMS or antibiotics does not currently feature in the UK MLA content map,¹⁶ although AMS is mentioned briefly in the GMC’s ‘Outcomes for graduates’ guidance.¹⁷ This, along with the challenges of tracking incidental teaching opportunities in clinical years, limits UK undergraduate curricula for meeting global competency targets. Targets laid out by the WHO curriculum assessment tool for AMR include verifying the capability and quality of training delivered by clinical staff, or a formal assessment of learner’s AMR knowledge and competencies.¹⁸ The WHO also provide a competency framework for healthcare worker’s education on AMR, breaking down desired competencies into knowledge, skills and attitudes for both prescribers and non-prescribers.⁹ The WHO framework acts as a reference for educators and accreditors for the development of curricula that not only provide the knowledge base to understand AMR control measures but also the ‘skills/attitudes to implement change’.⁹ Our data suggest current undergraduate teaching could be strengthened by greater parity with the aims of the skill/attitude elements of the WHO framework.

Our observations, ongoing concern over healthcare worker awareness, and the transition of AMR from an acute to a chronic issue on the UK national risk register,¹⁹ suggests a greater inclusion in the UK MLA content map is required. Addition of questions specific to AMR and AMS to the MLA question bank, alongside specific mention of learning needs in the content map itself, would provide greater focus for medical schools on desired skills by graduation. These questions should focus on exploring interpretative, practical understanding rather than basic science knowledge. Likewise, AMR’s continued inclusion in GMC guidance for graduates must move beyond aims to ‘describe…the role of pharmacogenomics and antimicrobial stewardship’,¹⁷ to require a practical skills base that will enable prescribers to engage meaningfully in AMS by graduation.

Strengths, limitations and future opportunities

Our data are limited by consideration of LOs self-identified by medical schools directly linked to AMR or AMS, rather than a full review of entire curricula. This may involve some selection bias on reported LOs and varied approaches to identifying them across schools. It is likely that our data may underappreciate the full exposure of medical students to topics relevant to AMR/AMS teaching. This is particularly the case where undergraduate curricula may also deliver on wider aspects of IPC and vaccine teaching and indirectly on patient-focused care and interprofessional development in line with GMC Good Medical Practice and GMC ‘Outcomes for graduates’ guidance than appears to be the case here.^16,17 Furthermore, our data cannot account for student outcomes and impact on postgraduate practice and behaviours based on the different approaches and provision of teaching. Understanding of these outcomes is critical for helping to understand the benefit of future education interventions. Our data, however, represent medical schools’ own understanding and intent to deliver on AMR/AMS teaching, providing an understanding of baseline delivery and highlighting potential opportunities for greater linking and equity of teaching to these core elements of education programmes, particularly for those following an integrated course. In some cases, our data identify a complete absence of targeted teaching for AMS. Further work is now required to interpret the practical effect of these observations with postgraduate outcomes and their impact on continued professional development, but this will remain difficult while a considerable portion of teaching isopportunistic and unrecorded.

Conclusion

AMR and AMS teaching across UK medical schools appears skewed towards knowledge-based outcomes and is less robust in developing practical skills for safe and confident antimicrobial prescribing. Clinical exposure during undergraduate training is often considered opportunistic and variable, an approach that is perhaps inadequate given concerns of sub-optimal awareness across healthcare workers.

Re-evaluation of early teaching strategies for this key public health priority is likely now required, shifting from opportunistic knowledge-based teaching to more skills-based AMS curricula, if the UK is to improve competency, confidence and uniformity of antimicrobial prescribing by graduation and meet targets set out in the 2024–2029 UK national action plan.⁴

Funding

This study was carried out as part of our routine work.

Transparency declarations

The following affiliations are unrelated to the submitted work or undergraduate education in general. Other potential interests, not in connection with this work, include: L.S.P.M. has consulted for or received speaker’s fees from bioMérieux (2013–2025), Eumedica (2016–2025), Pfizer (2018–2025), Sumitovant (2021–2023), Shionogi (2021–2025), Qiagen (2023), Gilead (2024), BioNTech (2024), Insmed (2024) and Advanz (2024–2025), and received research grants from the National Institute for Health and Care Research (2013–2025), CW + Charity (2018–2025), North West London Pathology (2022–2024), LifeArc (2020–2022), Shionogi (2024–2025), Infectopharm (2022–2024), the Joint Programming Initiative on AntiMicrobial Resistance (2023–2025) and the Healthcare Infection Society (2024–2025). S.E.B. received research support from Roche Pharma, educational support from Advanz Pharma, and has received consultancy and/or speaker fees from Sumitovant, Shionogi, the UK Clinical Pharmacy Association and bioMérieux. S.J.C.P. has previously received research grants from the Healthcare Infection Society and the Drummond Foundation not in connection with this work. S.J.C.P. was a Parliamentary Intern to the Office of Dr Danny Chambers MP for the British Society of Antimicrobial Chemotherapy (2024–2025). S.W. is funded by the British Society of Antimicrobial Chemotherapy for 7.5 h/week on a 12 month UK parliamentary internship with the office of Baroness Bennett. All other authors have nothing to declare.

Author contributions

S.J.C.P., Z.L.L. and L.S.P.M. devised the study. S.J.C.P. conducted the surveys. S.J.C.P. and Z.L.L. collected and analysed the data. All authors contributed to writing the draft manuscript. All authors provided feedback on the initial draft and agreed on the final draft for submission.