Research and analysis

ESPAUR report 2024 to 2025: lay summary

Updated 13 November 2025

Chapter 1. Introduction: Why surveillance is important to tackling antimicrobial resistance

ESPAUR is an acronym for the English Surveillance Programme for Antimicrobial Utilisation and Resistance.

It aims to collect data on the use of, and resistance to, antimicrobial medicines which are designed to treat infections that are caused by germs (microorganisms) such as:

• bacteria
• viruses
• fungi
• parasites

Those antimicrobial medicine types include antibacterials or antibiotics, antivirals, antifungals and antiparasitics (Figure 1). The most widely recognised type of antimicrobial medicine is antibiotics which are used to treat bacterial infections.

Bacteria, or other microorganisms, can become resistant by developing mechanisms to evade and survive these medicines. If this happens, it means that these antimicrobial medicines no longer work effectively against these infections. This is called antimicrobial resistance (AMR). By collecting data about these microorganisms, ESPAUR supports the aim of reducing AMR, as well as inappropriate antimicrobial use, which is one of the main drivers of resistant infections. It is important to know that AMR can result in harder to treat or even untreatable infections, which is why it has been recognised as an urgent global threat.

Figure 1. An overview of different types of antimicrobial medicines and the type of microorganisms they are used to treat

Accessible text for Figure 1

Figure 1 shows various types of antimicrobial medicines used to prevent and treat infections caused by microorganisms in humans, animals and plants. Antibiotics (antibacterials) prevent and treat bacterial infections such as respiratory or urinary tract infections, cellulitis and sexually transmitted infections such as gonorrhoea. Antivirals can prevent and treat viral infections such as colds, flu, chickenpox, COVID-19 and HIV. Antiparasitics prevent and treat infections caused by parasites such as malaria, threadworm and headlice. Antifungals prevent and treat fungal infections such as thrush, ringworm, athlete’s foot and fungal respiratory infections including aspergillosis.

End of accessible text

This report comprises chapters covering AMR, antimicrobial consumption, antimicrobial stewardship (that is educating and supporting healthcare professionals to follow evidence-based guidelines for prescribing and administering antimicrobials), improvement and assurance schemes that NHS England implement, as well as research initiatives and activities that members of the ESPAUR oversight group are undertaking to help tackle AMR.

Chapter 2. The rise of antimicrobial resistance

The UK Health Security Agency (UKHSA) collects, analyses and disseminates information about infections in England that are resistant to antimicrobials, focusing on bloodstream infections. This includes information on how many infections there are, where they are happening, who is being affected and how medicines are being prescribed. This chapter presents findings from this work and looks at how different factors affect the distribution of infections.

Antibiotic resistance

Figures on bloodstream infections due to bacteria, from 2024 show that there has been an overall increase in the number of bloodstream infections due to selected pathogens of public health importance (Escherichia coli (E. coli), Klebsiella pneumoniae, Klebsiella oxytoca, Pseudomonas spp., Acinetobacter spp., Staphylococcus aureus (S. aureus), Enterococcus spp., and Streptococcus pneumoniae), which increased by 5.7% since 2023, from 73,513 to 183,990. The incidence rate (cases per 100,000 people) saw a similar increase. This was mostly due to increases in rates of E. coli which make up most of these infections. These increases are following a substantial decline seen during the COVID-19 pandemic which have since recovered, such that, the 2024 saw a <1% increase in infections compared to 2019.

When looking at antibiotic-resistant bloodstream infections, following a decline during COVID-19 pandemic years (2020 and 2021) there have been subsequent year-on-year increases. Between 2019 and 2024, the number of antibiotic-resistant infections increased from 18,103 to 20,484 – an overall increase of 13.1%, most of which occurred in the last 2 years with a 9.3% rise since 2023. These infections include those caused by a defined set of important bacteria resistant to one or more bacteria of public health importance. The most common causative microorganisms were E. coli, K. pneumoniae, and K. oxytoca which, in 2024, made up 85.1% of the total. In 2024, as in previous years, E. coli was responsible for most cases of antibiotic-resistant bloodstream infections, making up 70.5% of the total in 2024.

The number of reported resistant infections had decreased during the pandemic, due to various factors such as reduced socialising, improved hand and respiratory hygiene (for example handwashing, covering coughs and sneezes, and wearing masks) and changes in healthcare-seeking behaviours (the actions people take to find medical care when they are unwell or require advice). The reduction in reported numbers may also have been caused, in part, by decreased detection of infections. The increases in the last 3 years were expected following removal of restrictions on socialising seen during the pandemic, but the extent of the rise is notable, with there now being more resistant infections than at any point on record.

This chapter also looks at carbapenemase-producing organisms (CPOs), a group of antibiotic-resistant microorganisms that are of particular concern and have been included as part of mandatory surveillance since 2020. The rate of reported CPOs has more than doubled between 2021 and 2024, although this is due in part to an increase in screening and reporting.

As in recent years, the report also takes a closer look at health inequalities in the context of the AMR burden, including factors such as ethnicity and deprivation. In this year’s report, rates by ethnic group are further age-sex standardised which means that it accounts for differences in age and sex distributions across different ethnic groups, allowing for a fairer comparison.

The highest number and rate of bloodstream infection episodes were observed among individuals of the white ethnic group. This group accounted for 88.4% of total bloodstream infections, of which 20.1% were resistant to at least one or more of the critically important antibiotics. This year’s report also included, age-sex standardised incidence rates, which showed that the Asian or Asian British ethnic group had a resistant bloodstream infection rate that was almost 2 times higher than the White ethnic group (92.5 versus 32.0 cases per 100,000 people).

Additionally, deprivation levels were looked at using indices of multiple deprivation (IMD), which is a combined measure of deprivation across various domains including income, employment, health, and education, within different geographical areas in the UK. In 2024, it was reported that areas with higher levels of deprivation had a greater burden of antibiotic-resistant bloodstream infections, with a 47.2% higher rate of resistant bloodstream infections compared to the lowest level (43.3 versus 29.4 cases per 100,000 people). The gap between the rate among the most and least deprived group has increased since 2019 when the rate in the most deprived group was 29.0% higher.

The report also presents infection data by age group. The burden of bloodstream infections, including those that were also resistant, was highest among adults aged 45 years or older, accounting for 87.7% and 89.5% cases, respectively. The highest rate was seen in those over 74 years, among both males and females.

The overall 30-day mortality rate (death within 30 days of the test that identified the infection) was 15.4% for selected Gram-negative bloodstream infections (E. coli, K. pneumoniae, Pseudomonas spp., Acinetobacter spp.). Mortality rate increased with age, being highest for adults aged 85 years and older (21.7%), with the exception of <1 year age group among whom mortality rate was 11.8%, which was greater than the 2.8% seen in the one to 14 years age group. Additionally, patients infected with a strain that was resistant to one or more of the critically important antibiotics had a higher mortality rate (17.2%) compared to those infected with susceptible strains which could be treated with the selected antibiotics (14.7%).

The incidence of fungal bloodstream infections was 3.9 cases per 100,000 people in 2024, increasing from the 3.4 cases per 100,000 people reported in 2020. This is thought to be in part due to improved detection and reporting.

By calculating the total burden of AMR, it is possible to track progress towards current targets aimed at preventing any increase in resistant infections in 2029 compared to the 2019 level, as set out in the UK government’s 5-year action plan for antimicrobial resistance 2024 to 2029. In England, a 22.7% increase in a selected set of antibiotic-resistant infections was reported, increasing from 9,922 infections in FY 2019 to 2020 to 12,175 infections in FY 2024 to 2025. This shows that AMR remains a problem and that we have work to do in terms of using antibiotics and other antimicrobial medicines more responsibly. The next chapter on antimicrobial consumption provides additional information.

Chapter 3. Curbing the consumption of antimicrobials

Antimicrobial medicines are necessary for many health conditions, as well as medical procedures such as C-sections, hip replacements and some forms of cancer treatment. But every time an antimicrobial is prescribed, there is a risk that AMR could develop or worsen. This is why it is so important that antimicrobial medicines like antibiotics are used appropriately. In short, they should be prescribed at the right times and for the right reasons.

A new National Action Plan (NAP) was published in 2024 outlining the strategy for tackling AMR in the UK over the next 5 years, including setting out targets for antimicrobial use. The ambition is to reduce total antimicrobial use in humans by 5% by 2029, compared to the figure for 2019. These goals should help keep prescribers working hard to reduce the amount of inappropriate antimicrobial medicines being used. UKHSA supports work towards these objectives by publishing data on the amount of antimicrobial use and the infections they are being used for.

As of 2024, antimicrobial use is down 2% since 2019 but was heavily disrupted by the COVID-19 pandemic, making it difficult to understand trends. In 2024, the total antibiotic consumption was 17.5 daily defined doses (DDD) per 1,000 inhabitants per day (DID), which is a small (0.9%) increase since 2023. This works out to about 6.4 doses per person per year. This needs to be reduced to below 6.2 to meet the NAP target by 2029.

Antibiotic use in 2024 was lower than in 2019 across most treatment settings, for example in GPs and hospital outpatients. However, there has been a 2.7% increase in antibiotic prescribing for hospital inpatients. In addition, there has been a large increase in prescribing in community pharmacies, due to the introduction of the Pharmacy First service in 2024.

Most antibiotics in England are prescribed in GP settings, which continued in 2024, accounting for 70.4% of all prescriptions. Because of this, GPs are important places to study to make sure that antibiotics are being prescribed appropriately.

The number of prescriptions varies by region, with the highest DID in the North East and the lowest in London. These differences are due to multiple factors, including age and deprivation. For example, London has the second highest rate of hospital prescriptions, despite having the lowest primary care rate, reflecting a younger population. The North East has areas with higher levels of deprivation and older populations, who require more healthcare, but lower provision of GP services compared to some regions.

A breakdown by antibiotic group revealed that penicillins were the most used antibiotic group in both primary and secondary care. Consumption across antibiotic groups remained lower than 2019 levels, with the exception of a few groups, such as anti-C. difficile drugs, sulfonamides and trimethoprim, and first- and second-generation cephalosporins. The increased consumption of anti-C. difficile drugs were likely due to recent increases in C. difficile infections.

There have been significant efforts to reduce treatment durations for particular antibiotics in order to reduce total antimicrobial prescribing. Updates to national guidelines, which recommend shortened regimens where appropriate for certain antibiotics and medical conditions, have also been shown to have a positive impact on reducing total consumption.

Total antifungal consumption was at a similar level in 2024 compared to 2019, with a small increase of 2.0%. There was a large decrease in 2020 due to the COVID-19 pandemic, but there has since been a steady increase every year. Between 2020 and 2024, antifungal use has increased by 33.5% in primary care and 11.7% in NHS acute trusts.

Use of COVID-19 antivirals reduced by 29.7% in 2024 compared to 2023, reflecting the reduction in COVID-19 cases and changes in testing and guidance.

In antiparasitics, use of quinine – an antiparasitic used mainly to treat malaria – has been decreasing since 2019. Use of mebendazole, used for threadworm infections, has also been declining since 2019. Use of albendazole has decreased in 2024 following a large increase of 75% between 2021 and 2023.

Chapter 4. Protecting antimicrobials: the importance of antimicrobial stewardship

To tackle AMR, it is important to act on several fronts so that we use these medicines wisely and reduce the spread of resistant infections. One aspect of this effort is antimicrobial stewardship (AMS). This supports healthcare workers in carefully selecting the most appropriate antimicrobial medicine, accurate dose and treatment length. These strategies also contribute towards the UK National Action Plan target of reducing antimicrobial use in humans by 5% between 2019 and 2029. In the efforts to use antimicrobials wisely and effectively, several helpful tools and resources have been developed. This chapter provides a summary of the main national primary and secondary care AMS interventions.

One example is the TARGET toolkit, which is an acronym for ‘Treat Antibiotics Responsibly, Guidance, Education and Tools’, aimed at use in the primary care setting, providing the tools and resources to improve use of antimicrobials and champion AMS activities.

The ‘Cycle of AMS’ infographic has now been included in TARGET. It shows AMS as a continuous process and highlights key steps. This infographic was created in response to feedback from primary care staff, who indicated the need for a consistent approach to AMS. In addition, TARGET has published new resources to inform the use of antibiotics in urinary tract infections (UTIs), adding to the ‘How to…?’ series for reviewing patients on long-term antibiotics. These tools, along with those from previous years, can guide doctors in making the right decisions about when and how to prescribe life-saving antibiotics to ensure they are used appropriately.

TARGET are also developing a tool for care home staff to support recognition and communication around suspected UTI, improve adherence to national guidelines on AMS and UTI, and promote self-care. As part of the initial 2024 pilot, the tool was adapted to integrate into care homes’ digital reporting systems. A further pilot will take place in 2025 to evaluate and test usability of the tool.

The UK has recently adapted new AWaRe categories for primary and secondary care. AWaRe is an acronym for Access, Watch and Reserve, which are 3 of the categories, along with Other. This gives information to prescribers about the situations in which they should use each antibiotic. The Access group are for specific infections and have little risk of developing resistance. The Watch group have higher risk of developing resistance, and their use should therefore be monitored. Reserve antibiotics should be saved for very specific situations where the patient is severely ill, and other antibiotics have not worked. UKHSA has recently published several materials to communicate these changes and provide an easy-to-access list of each antibiotic and its category.

Additionally, UKHSA have conducted reviews of the scientific literature to learn more about issues related to AMS around the world, such as the role of pharmacists in disease outbreaks and what measures are used to assess whether prescriptions are appropriate.

Pharmacy healthcare professionals play a crucial role in AMS, particularly due to their expertise in medications and direct patient interactions. Tools are available to help pharmacists and other professionals understand and communicate about antibiotics effectively.

By following the AMS guidelines, we can preserve the effectiveness of antimicrobial medicines like antibiotics, ultimately benefiting patient-centred care and public health. Additionally, it’s important to consider factors like deprivation and specific clinical conditions when managing infections to address health inequalities and improve outcomes for everyone.

Chapter 5. NHS England: improvement and assurance schemes

NHS England works on different programmes to improve healthcare to ensure antimicrobials are used wisely. They have schemes to encourage healthcare providers to use these medicines carefully to benefit patients and prevent AMR. These include the:

• NHS Oversight Framework
• National Medicines Optimisation Opportunities
• Pharmacy First for community pharmacies
• NHS Standard Contract for acute hospitals
• National Blood Culture Pathway

To take the NHS Oversight Framework as an example, its aims include providing alignment of priorities across NHS and wider healthcare partners. It works to establish a consistent and transparent method for assessing performance across integrated care boards (ICBs) and NHS trusts or foundation trusts. Targets for antibiotic prescribing in primary care monitor how well different areas are meeting these targets. It uses 2 main metrics:

• number of antibiotics being prescribed in primary care
• the percentage of broad-spectrum antibiotics being prescribed in primary care

Total primary care prescribing in the 12 broad-spectrum antibiotics, for example amoxicillin, can treat a wide range of bacteria. They are useful when doctors are unsure which bacteria is causing the infection but must be used with caution as they can also harm good bacteria in the body and increase risk of antibiotic resistance. In the past year, some areas met these targets, while others did not. Overall, there was an improvement in performance compared with the previous year and levels remain below the target of maintaining broad-spectrum antibiotics at or less than 10% of total antibiotics.

The Pharmacy First scheme, which launched in January 2024, aims to free up GP appointments for patients who need them most by providing people with safe and high-quality healthcare, with faster and more convenient access. The 3 main reasons patients can present at or be referred to community pharmacy include minor illness management, supply of urgent repeat medication and clinical assessment for 7 common infection pathways. During 2024 to 2025 financial year, there were over 2 million consultations delivered in English community pharmacies across these 7 infection pathways.

The NHS England Medicines Optimisation Executive Group identified 16 opportunities for improved medicine use, including reducing course length for antimicrobial prescribing. One of the key measures of this is increasing the proportion of amoxicillin prescriptions that are 5-day courses, as opposed to longer courses. This proportion increased from 57% in March 2024 to 69% in March 2025.

Additionally, the National Blood Culture Pathway, is an ongoing quality improvement initiative to improve methods for blood culture collection that if not adhered to would have the potential to lead to either false positive or negative results, including guidance to fill bottles with the correct volume of blood and processing in a timely manner.

All these efforts are part of a bigger plan to make sure patients get the antibiotic best suited for the bacterial infection they have. This will help to improve patient outcomes while also tackling resistance.

Chapter 6. Professional education, training and public engagement

Public and professional engagement as well as education are key aspects of antimicrobial stewardship (AMS). In the UK, healthcare professionals are actively working to educate and empower patients and the public, as well as other stakeholders about the responsible use of antibiotics.

UKHSA works with the Royal College of General Practitioners (RCGP) aiming to promote awareness of AMR and engagement with TARGET among prescribers in general practice. In 2024 to 2025, this included 3 webinars, on topics such as the patient perception of infections and antibiotics, navigating AMS for prescribers, and managing recurrent urinary tract infections in primary care. These were well-attended with over 1,000 attendees and received a high satisfaction rating. These resources have been added to the TARGET website for future use.

TARGET training has been rolled out across England to help healthcare professionals to improve how antibiotics are prescribed in primary care. An evaluation of the training showed that it was useful and increased confidence and motivation to apply what they had learned. Early results suggest that training helped reduce antibiotic prescriptions with a 6.1% reduction in dispensing among GP practices where training was provided compared to those which had not.

Additionally, a free eLearning course developed in collaboration with the British Society for Antimicrobial Chemotherapy (BSAC) for the FutureLearn platform, to help improve prescribing of antibiotics in primary care was refreshed, comprising 5 hour-long modules. In total, there were 555 enrolments of which 63% engaged with content by viewing at least one module, between April 2024 to March 2025.

A public survey conducted by UKHSA in 2023 highlighted gaps in knowledge of AMR, particularly in men, younger adults and those from black and Asian ethnic groups. As a result, the UKHSA launched a public campaign using Andi Biotic as a mascot to deliver educational messages, which successfully captured the attention of the target audience.

The annual campaign Antibiotic Guardian encourages healthcare organisations, GP practices, hospitals, community pharmacies, farmers, patients and the public to pledge responsible use of antibiotics. In 2024, over 100 organisations, including some from abroad, registered their efforts on the Antibiotic Guardian website. In 2024, a total of 12,967 pledges were received, bringing the cumulative number of pledges since the inception of the campaign in 2014 to 190,648. Antibiotic Guardian had its seventh learning and awards event in June 2025, where 48 projects and case studies,  were shortlisted from a total of 75 entries across 13 categories. Shortlisted posters and presentations were also shared on the Antibiotic Guardian web page.

Interactive programmes such as Antibiotic Guardian raise the level of professional, patient and public understanding around antibiotic use, and will help us to include them in the effort to tackle AMR collectively.

Chapter 7. Recent research initiatives

While progress has been made in recent years to reduce inappropriate antibiotic use in the UK, it is important that this continues so we can make sure the best outcomes are provided for patients in future. This can be achieved partly by implementing what we already understand about healthcare-associated infections and AMR, but it is also vital that scientists and healthcare professionals continue to improve their understanding through scientific research. The publication of the UK NAP for 2024 to 2029 also identified some key research priorities, with many of the projects highlighted in the chapter aligning closely with the upcoming NAP commitments.

Healthcare-associated infections and AMR have been the subject of many important UK research projects over the last year and have resulted in over 100 scientific papers from UKHSA, each one reviewed and approved by experts in the field. The number of publications published by NAP outcome are listed below:

• IPC and infection management (21)

• public engagement and education (2)

• strengthened surveillance (13)

• antimicrobial stewardship and disposal (14)

• AMR workforce (4)

• innovation and influence (10)

• using information for action (21)

• health disparities and health inequalities (11)

• AMR diplomacy (10)

Several research projects conducted from April 2024 to March 2025 were also highlighted in the chapter, comprising:

• prescribing and antimicrobial consumption
• infection prevention and control
• inequalities and risk factors
• surveillance
• primary care
• new vaccines and treatments

This commitment to improving scientific knowledge is reflected in the funding of 2 specialist research units between April 2020 and March 2025, called Health Protection Research Units (HPRUs), dedicated to studying healthcare-associated infections and AMR. One is at the University of Oxford and the other at Imperial College London. The research conducted at these units aims to improve public health policies and practices and are essential for keeping patients and the public safe and healthy.

Importantly, this research has also started to focus more on how we can address inequalities in health. Understanding how different groups of people are affected by healthcare-associated infections and AMR can help us to improve outcomes for everyone in future.

Chapter 8. Support from stakeholders

The production of the ESPAUR report benefits greatly from the input of experts from various organisations, each bringing diverse perspectives to the table. In total, 14 different stakeholders contributed to this year’s report:

• British Dental Association (BDA)
• British Infection Association (BIA)
• British Society for Antimicrobial Chemotherapy (BSAC)
• Care Quality Commission (CQC)
• College of General Dentistry (CGDent)
• IQVIA
• Royal College of General Practitioners
• Royal College of Nursing
• Rx-Info
• Veterinary Medicines Directorate, Department for Environment, Food and Rural Affairs (VMD – Defra)
• Scottish One Health Antimicrobial Use and Antimicrobial Resistance (SONAAR)
• Public Health Agency, Northern Ireland
• Public Health Wales (PHW)
• NHS England (NHSE)

As well as contributing information to the report, these stakeholders are part of the ESPAUR Oversight Group, which consists of over 30 stakeholder members. They engage in various activities that support the national effort to tackle healthcare-associated infections and AMR. These activities include:

• promoting the appropriate use of antimicrobials
• attending international AMR conferences to ensure partnership in tackling AMR
• delivering workshops and professional educational programmes on infection prevention
• producing guidelines and educational resources

Writing the ESPAUR report with the input of stakeholders from various organisations with their own unique experiences of performing activities aiming to tackle AMR is helping us all to build a more strategic agenda and plan to improve outcomes in future.

Chapter 9. Feedback from stakeholders and report users

Over the past 10 years, the ESPAUR report has broadened and diversified its content to extend beyond AMR. To accompany the report, UKHSA hosts a webinar to present key insights to stakeholders, and feedback surveys are used to gather information on the report’s usage.

Most feedback received from users of the 2023 to 2024 report has been positive, with 92% (out of 389 respondents) endorsing the ESPAUR report to other stakeholders. Some of the key findings included:

• the most common job role of respondents was reported as pharmacist, accounting for 34% of responses, followed by IPC specialists and doctors
• infographics, which were used to highlight key messages and statistics in the report, were reported to be useful by most respondents (84% of 261)
• the most used chapters of the report were AMR (68% of 201 respondents), AMS (54%), and antimicrobial consumption (45%) chapters
• many respondents (48%) said they accessed 3 or more chapters
• the most common reasons for accessing the report were gathering information (19% of 308 respondents), personal learning (10%), and sharing information with others (10%)

What can we do to tackle AMR together?

As we have seen in this latest ESPAUR report, levels of infections and antimicrobial resistance have been increasing in England in recent years.

We all have a role to play in tackling these increases. The public can play as important a part as anyone in keeping the level of infections low.

Some actions you can take to help reduce infection levels are:

• regular personal hygiene such as handwashing with soap and water, dental and oral care, and practicing good respiratory hygiene (for example covering your mouth and nose with a tissue or elbow when coughing or sneezing)
• understanding and practicing good environmental hygiene, such as proper food preparation and damp control
• only taking antibiotics when prescribed by a qualified healthcare professional and completing the full course exactly as directed
• being aware of One Health – an approach that recognises how closely connected the health of humans, animals (including pets), plants, and the environment are, as it relates to you
• staying hydrated as an effective way of preventing infections such as UTIs

You can find out more about how to protect these vital medicines at Antibiotic Guardian.

Acknowledgements

Vanessa Carter, Paul Klinger, Beverly Harris, Zahin Amin-Chowdhury, Matt Wilson, Karina Micah, Ellie Tang, Diane Ashiru-Oredope.