Antimicrobial stewardship in UK special care baby units: gaps in research and future directions

Despite a significant decline in the incidence of neonatal sepsis, the clinical imperative to avoid missing life-threatening infection continues to drive widespread antibiotic overprescription. Antimicrobial stewardship is universally recognized and explicitly mandated within the UK 2024–2029 National Action Plan on Antimicrobial Resistance as a critical mechanism to combat resistance and prevent iatrogenic harms related to infant dysbiosis. However, a major misalignment exists within the current evidence base: most of the neonatal stewardship research is conducted in highly resourced, tertiary Neonatal Intensive Care Units (Level 3), even though most postnatal inpatient care occurs in Special Care Baby Units (Level 1) and Local Neonatal Units (Level 2). This Viewpoint explores the operational and structural barriers that limit the transferability of intensive-care stewardship models to lower-acuity settings, identifies key research gaps around baseline prescribing practices and multidisciplinary collaboration, and argues for the inclusion of Level 1 and 2 populations in future validation studies of emerging diagnostic tools for neonatal sepsis.