The objective of this study was to establish how antibiotic prescribing policies at National Health Service (NHS) hospitals match the England Department of Health ‘Start Smart—Then Focus’ recommendations and relate to Clostridium difficile infection (CDI) rates.


Antibiotic pharmacists were surveyed regarding recommendations for empirical treatment of common syndromes (‘Start Smart’) and antimicrobial prescription reviews (‘Focus’) at their hospital trusts. If no response was provided, policy data were sought from trust websites and the MicroGuide app (Horizon Strategic Partners, UK). Empirical treatment recommendations were categorized as broad spectrum (a β-lactam penicillin/β-lactamase inhibitor, cephalosporin, quinolone or carbapenem) or narrow spectrum. CDI rates were gathered from the national mandatory surveillance system.