Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine

Roman Yulianovych Grytsko

doi:doi:10.11648/j.wjhpm.20260101.12

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Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine

Roman Yulianovych Grytsko^*

Published in World Journal of Health Policy and Management (Volume 1, Issue 1)

Received: 13 August 2026 Accepted: 22 August 2026 Published: 22 September 2026

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Abstract

Background: Antimicrobial resistance (AMR) remains a growing global health threat, and in Ukraine the burden is compounded by unregulated over-the-counter access to antibiotics, disruption of routine immunization, and reduced microbiological diagnostic capacity across primary care facilities reorganized into Territorial Medical Associations (TMOs) since the 2018 healthcare reform, all occurring against the backdrop of full-scale war. AMR stewardship at the primary-care level continues to be framed almost exclusively as a clinical rather than a managerial task, which weakens the effectiveness of local antibiotic stewardship programs. Objective: To substantiate a practical framework that integrates evidence-based clinical principles of rational antibiotic therapy with institutional management mechanisms at the primary healthcare facility level, in order to strengthen AMR containment in primary care under conflict conditions. Methods: A narrative synthesis of international evidence on AMR control was conducted, covering the One Health concept, the “Start Smart – Then Focus” antibiotic stewardship principle, the WHO AWaRe antibiotic classification, point-of-care diagnostics, and immunization policy, integrated with the authors’ own prior work on managerial dysfunction in Ukraine’s polyclinic-outpatient network. Sources were retrieved from Cochrane Library, PubMed/MEDLINE and Journal Citation Reports-indexed journals, prioritizing systematic reviews, meta-analyses and multicentre validation studies published through 2026. Results: Five interdependent levers were identified as decisive for stewardship effectiveness at the facility level: a locally adapted first-line antibiotic formulary; routine antimicrobial consumption monitoring; prescribing audit and feedback; point-of-care C-reactive protein and rapid antimicrobial susceptibility testing; and vaccination policy as an upstream AMR-prevention tool. Conflict-related amplifiers — including extensively drug-resistant Gram-negative pathogens associated with war wounds and their documented spread into referral networks — further elevate the managerial stakes for primary care. Conclusion: Containing AMR in primary care is a joint clinical-managerial task. Evidence robustly supports each stewardship element individually, but institutional mechanisms determine whether these elements are reproduced systematically across a facility rather than remaining dependent on individual clinician initiative. Treating antibiotic stewardship as a management function of the TMO, not solely an individual physician’s discipline, is a promising direction for strengthening national AMR control programs under wartime conditions.

Published in	World Journal of Health Policy and Management (Volume 1, Issue 1)
DOI	10.11648/j.wjhpm.20260101.12
Page(s)	8-12
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2026. Published by Science Publishing Group

Keywords

Antimicrobial Resistance, Antibiotic Stewardship, Primary Health Care, One Health, Healthcare Management, Point-of-Care Testing, Vaccination, Conflict-Affected Health Systems

References

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[2]	GBD 2021 Antimicrobial Resistance Collaborators. Global burden of bacterial antimicrobial resistance 1990–2021: a systematic analysis with forecasts to 2050. The Lancet. 2024, 404(10459), 1199–1226. https://doi.org/10.1016/S0140-6736(24)01867-1
[3]	United Nations. Political Declaration of the High-Level Meeting on Antimicrobial Resistance. [Internet]. 2024. Available from: https://www.un.org/pga/wp-content/uploads/sites/108/2024/09/FINAL-Text-AMR-to-PGA.pdf [Accessed 13 August 2026].
[4]	Aabenhus, R., Jensen, J. U., Jørgensen, K. J., Hróbjartsson, A., Bjerrum, L. Biomarkers as point-of-care tests to guide prescription of antibiotics in patients with acute respiratory infections in primary care. Cochrane Database of Systematic Reviews. 2014, Issue 11, Art. No. CD010130. https://doi.org/10.1002/14651858.CD010130.pub2
[5]	Van Hecke, O., Bjerrum, L., Gentile, I., et al. Guidance on C-reactive protein point-of-care testing and complementary strategies to improve antibiotic prescribing for adults with lower respiratory tract infections in primary care. Frontiers in Medicine. 2023, 10, Art. 1166742. https://doi.org/10.3389/fmed.2023.1166742
[6]	Spurling, G. K. P., Dooley, L., Clark, J., Askew, D. A. Immediate versus delayed versus no antibiotics for respiratory infections. Cochrane Database of Systematic Reviews. 2023, Issue 10, Art. No. CD004417. https://doi.org/10.1002/14651858.CD004417.pub6
[7]	Vekemans, J., Hasso-Agopsowicz, M., Kang, G., et al. Leveraging vaccines to reduce antibiotic use and prevent antimicrobial resistance: a World Health Organization action framework. Clinical Infectious Diseases. 2021, 73(4), e1011–e1017. https://doi.org/10.1093/cid/ciab062
[8]	Elshenawy, R. A., Umaru, N., Aslanpour, Z. WHO AWaRe classification for antibiotic stewardship: tackling antimicrobial resistance — a descriptive study from an English NHS Foundation Trust prior to and during the COVID-19 pandemic. Frontiers in Microbiology. 2023, 14, Art. 1298858. https://doi.org/10.3389/fmicb.2023.1298858
[9]	Reyburn, R., Maher, J., von Mollendorf, C., et al. The impact of the introduction of ten- or thirteen-valent pneumococcal conjugate vaccines on antimicrobial-resistant pneumococcal disease and carriage: a systematic literature review. Journal of Global Health. 2023, 13, Art. 05001. https://doi.org/10.7189/jogh.13.05001
[10]	Åkerlund, A., Jonasson, E., Matuschek, E., Serrander, L., Sundqvist, M., Kahlmeter, G.; the RAST Study Group. EUCAST rapid antimicrobial susceptibility testing (RAST) in blood cultures: validation in 55 European laboratories. Journal of Antimicrobial Chemotherapy. 2020, 75(11), 3230–3238. https://doi.org/10.1093/jac/dkaa333
[11]	Ayosanmi, O. S., Alli, B. Y., Akingbule, O. A., Alaga, A. H., Perepelkin, J., Marjorie, D., Sansgiry, S. S., Taylor, J. Prevalence and correlates of self-medication practices for prevention and treatment of COVID-19: a systematic review. Antibiotics. 2022, 11(6), Art. 808. https://doi.org/10.3390/antibiotics11060808
[12]	Gulliford, M. C., Prevost, A. T., Charlton, J., et al. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ. 2019, 364, Art. l236. https://doi.org/10.1136/bmj.l236
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Grytsko, R. Y. (2026). Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World Journal of Health Policy and Management, 1(1), 8-12. https://doi.org/10.11648/j.wjhpm.20260101.12

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ACS Style

Grytsko, R. Y. Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World J. Health Policy Manag. 2026, 1(1), 8-12. doi: 10.11648/j.wjhpm.20260101.12

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AMA Style

Grytsko RY. Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World J Health Policy Manag. 2026;1(1):8-12. doi: 10.11648/j.wjhpm.20260101.12

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@article{10.11648/j.wjhpm.20260101.12,
  author = {Roman Yulianovych Grytsko},
  title = {Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine},
  journal = {World Journal of Health Policy and Management},
  volume = {1},
  number = {1},
  pages = {8-12},
  doi = {10.11648/j.wjhpm.20260101.12},
  url = {https://doi.org/10.11648/j.wjhpm.20260101.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.wjhpm.20260101.12},
  abstract = {Background: Antimicrobial resistance (AMR) remains a growing global health threat, and in Ukraine the burden is compounded by unregulated over-the-counter access to antibiotics, disruption of routine immunization, and reduced microbiological diagnostic capacity across primary care facilities reorganized into Territorial Medical Associations (TMOs) since the 2018 healthcare reform, all occurring against the backdrop of full-scale war. AMR stewardship at the primary-care level continues to be framed almost exclusively as a clinical rather than a managerial task, which weakens the effectiveness of local antibiotic stewardship programs. Objective: To substantiate a practical framework that integrates evidence-based clinical principles of rational antibiotic therapy with institutional management mechanisms at the primary healthcare facility level, in order to strengthen AMR containment in primary care under conflict conditions. Methods: A narrative synthesis of international evidence on AMR control was conducted, covering the One Health concept, the “Start Smart – Then Focus” antibiotic stewardship principle, the WHO AWaRe antibiotic classification, point-of-care diagnostics, and immunization policy, integrated with the authors’ own prior work on managerial dysfunction in Ukraine’s polyclinic-outpatient network. Sources were retrieved from Cochrane Library, PubMed/MEDLINE and Journal Citation Reports-indexed journals, prioritizing systematic reviews, meta-analyses and multicentre validation studies published through 2026. Results: Five interdependent levers were identified as decisive for stewardship effectiveness at the facility level: a locally adapted first-line antibiotic formulary; routine antimicrobial consumption monitoring; prescribing audit and feedback; point-of-care C-reactive protein and rapid antimicrobial susceptibility testing; and vaccination policy as an upstream AMR-prevention tool. Conflict-related amplifiers — including extensively drug-resistant Gram-negative pathogens associated with war wounds and their documented spread into referral networks — further elevate the managerial stakes for primary care. Conclusion: Containing AMR in primary care is a joint clinical-managerial task. Evidence robustly supports each stewardship element individually, but institutional mechanisms determine whether these elements are reproduced systematically across a facility rather than remaining dependent on individual clinician initiative. Treating antibiotic stewardship as a management function of the TMO, not solely an individual physician’s discipline, is a promising direction for strengthening national AMR control programs under wartime conditions.},
 year = {2026}
}

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TY  - JOUR
T1  - Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine
AU  - Roman Yulianovych Grytsko
Y1  - 2026/09/22
PY  - 2026
N1  - https://doi.org/10.11648/j.wjhpm.20260101.12
DO  - 10.11648/j.wjhpm.20260101.12
T2  - World Journal of Health Policy and Management
JF  - World Journal of Health Policy and Management
JO  - World Journal of Health Policy and Management
SP  - 8
EP  - 12
PB  - Science Publishing Group
UR  - https://doi.org/10.11648/j.wjhpm.20260101.12
AB  - Background: Antimicrobial resistance (AMR) remains a growing global health threat, and in Ukraine the burden is compounded by unregulated over-the-counter access to antibiotics, disruption of routine immunization, and reduced microbiological diagnostic capacity across primary care facilities reorganized into Territorial Medical Associations (TMOs) since the 2018 healthcare reform, all occurring against the backdrop of full-scale war. AMR stewardship at the primary-care level continues to be framed almost exclusively as a clinical rather than a managerial task, which weakens the effectiveness of local antibiotic stewardship programs. Objective: To substantiate a practical framework that integrates evidence-based clinical principles of rational antibiotic therapy with institutional management mechanisms at the primary healthcare facility level, in order to strengthen AMR containment in primary care under conflict conditions. Methods: A narrative synthesis of international evidence on AMR control was conducted, covering the One Health concept, the “Start Smart – Then Focus” antibiotic stewardship principle, the WHO AWaRe antibiotic classification, point-of-care diagnostics, and immunization policy, integrated with the authors’ own prior work on managerial dysfunction in Ukraine’s polyclinic-outpatient network. Sources were retrieved from Cochrane Library, PubMed/MEDLINE and Journal Citation Reports-indexed journals, prioritizing systematic reviews, meta-analyses and multicentre validation studies published through 2026. Results: Five interdependent levers were identified as decisive for stewardship effectiveness at the facility level: a locally adapted first-line antibiotic formulary; routine antimicrobial consumption monitoring; prescribing audit and feedback; point-of-care C-reactive protein and rapid antimicrobial susceptibility testing; and vaccination policy as an upstream AMR-prevention tool. Conflict-related amplifiers — including extensively drug-resistant Gram-negative pathogens associated with war wounds and their documented spread into referral networks — further elevate the managerial stakes for primary care. Conclusion: Containing AMR in primary care is a joint clinical-managerial task. Evidence robustly supports each stewardship element individually, but institutional mechanisms determine whether these elements are reproduced systematically across a facility rather than remaining dependent on individual clinician initiative. Treating antibiotic stewardship as a management function of the TMO, not solely an individual physician’s discipline, is a promising direction for strengthening national AMR control programs under wartime conditions.
VL  - 1
IS  - 1
ER  -

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Roman Yulianovych Grytsko

Department of Infectious Diseases, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

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http://orcid.org/0000-0001-7086-8399

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Grytsko, R. Y. (2026). Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World Journal of Health Policy and Management, 1(1), 8-12. https://doi.org/10.11648/j.wjhpm.20260101.12

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ACS Style

Grytsko, R. Y. Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World J. Health Policy Manag. 2026, 1(1), 8-12. doi: 10.11648/j.wjhpm.20260101.12

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AMA Style

Grytsko RY. Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine. World J Health Policy Manag. 2026;1(1):8-12. doi: 10.11648/j.wjhpm.20260101.12

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@article{10.11648/j.wjhpm.20260101.12,
  author = {Roman Yulianovych Grytsko},
  title = {Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine},
  journal = {World Journal of Health Policy and Management},
  volume = {1},
  number = {1},
  pages = {8-12},
  doi = {10.11648/j.wjhpm.20260101.12},
  url = {https://doi.org/10.11648/j.wjhpm.20260101.12},
  eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.wjhpm.20260101.12},
  abstract = {Background: Antimicrobial resistance (AMR) remains a growing global health threat, and in Ukraine the burden is compounded by unregulated over-the-counter access to antibiotics, disruption of routine immunization, and reduced microbiological diagnostic capacity across primary care facilities reorganized into Territorial Medical Associations (TMOs) since the 2018 healthcare reform, all occurring against the backdrop of full-scale war. AMR stewardship at the primary-care level continues to be framed almost exclusively as a clinical rather than a managerial task, which weakens the effectiveness of local antibiotic stewardship programs. Objective: To substantiate a practical framework that integrates evidence-based clinical principles of rational antibiotic therapy with institutional management mechanisms at the primary healthcare facility level, in order to strengthen AMR containment in primary care under conflict conditions. Methods: A narrative synthesis of international evidence on AMR control was conducted, covering the One Health concept, the “Start Smart – Then Focus” antibiotic stewardship principle, the WHO AWaRe antibiotic classification, point-of-care diagnostics, and immunization policy, integrated with the authors’ own prior work on managerial dysfunction in Ukraine’s polyclinic-outpatient network. Sources were retrieved from Cochrane Library, PubMed/MEDLINE and Journal Citation Reports-indexed journals, prioritizing systematic reviews, meta-analyses and multicentre validation studies published through 2026. Results: Five interdependent levers were identified as decisive for stewardship effectiveness at the facility level: a locally adapted first-line antibiotic formulary; routine antimicrobial consumption monitoring; prescribing audit and feedback; point-of-care C-reactive protein and rapid antimicrobial susceptibility testing; and vaccination policy as an upstream AMR-prevention tool. Conflict-related amplifiers — including extensively drug-resistant Gram-negative pathogens associated with war wounds and their documented spread into referral networks — further elevate the managerial stakes for primary care. Conclusion: Containing AMR in primary care is a joint clinical-managerial task. Evidence robustly supports each stewardship element individually, but institutional mechanisms determine whether these elements are reproduced systematically across a facility rather than remaining dependent on individual clinician initiative. Treating antibiotic stewardship as a management function of the TMO, not solely an individual physician’s discipline, is a promising direction for strengthening national AMR control programs under wartime conditions.},
 year = {2026}
}

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TY  - JOUR
T1  - Integrating Clinical Stewardship and Institutional Management to Control Antimicrobial Resistance in Primary Care During Wartime in Ukraine
AU  - Roman Yulianovych Grytsko
Y1  - 2026/09/22
PY  - 2026
N1  - https://doi.org/10.11648/j.wjhpm.20260101.12
DO  - 10.11648/j.wjhpm.20260101.12
T2  - World Journal of Health Policy and Management
JF  - World Journal of Health Policy and Management
JO  - World Journal of Health Policy and Management
SP  - 8
EP  - 12
PB  - Science Publishing Group
UR  - https://doi.org/10.11648/j.wjhpm.20260101.12
AB  - Background: Antimicrobial resistance (AMR) remains a growing global health threat, and in Ukraine the burden is compounded by unregulated over-the-counter access to antibiotics, disruption of routine immunization, and reduced microbiological diagnostic capacity across primary care facilities reorganized into Territorial Medical Associations (TMOs) since the 2018 healthcare reform, all occurring against the backdrop of full-scale war. AMR stewardship at the primary-care level continues to be framed almost exclusively as a clinical rather than a managerial task, which weakens the effectiveness of local antibiotic stewardship programs. Objective: To substantiate a practical framework that integrates evidence-based clinical principles of rational antibiotic therapy with institutional management mechanisms at the primary healthcare facility level, in order to strengthen AMR containment in primary care under conflict conditions. Methods: A narrative synthesis of international evidence on AMR control was conducted, covering the One Health concept, the “Start Smart – Then Focus” antibiotic stewardship principle, the WHO AWaRe antibiotic classification, point-of-care diagnostics, and immunization policy, integrated with the authors’ own prior work on managerial dysfunction in Ukraine’s polyclinic-outpatient network. Sources were retrieved from Cochrane Library, PubMed/MEDLINE and Journal Citation Reports-indexed journals, prioritizing systematic reviews, meta-analyses and multicentre validation studies published through 2026. Results: Five interdependent levers were identified as decisive for stewardship effectiveness at the facility level: a locally adapted first-line antibiotic formulary; routine antimicrobial consumption monitoring; prescribing audit and feedback; point-of-care C-reactive protein and rapid antimicrobial susceptibility testing; and vaccination policy as an upstream AMR-prevention tool. Conflict-related amplifiers — including extensively drug-resistant Gram-negative pathogens associated with war wounds and their documented spread into referral networks — further elevate the managerial stakes for primary care. Conclusion: Containing AMR in primary care is a joint clinical-managerial task. Evidence robustly supports each stewardship element individually, but institutional mechanisms determine whether these elements are reproduced systematically across a facility rather than remaining dependent on individual clinician initiative. Treating antibiotic stewardship as a management function of the TMO, not solely an individual physician’s discipline, is a promising direction for strengthening national AMR control programs under wartime conditions.
VL  - 1
IS  - 1
ER  -

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