Built environment stewardship (BESt) - the missing pillar of antimicrobial resistance (AMR) action plans

Identifying risk is central to tackling antimicrobial resistance (AMR); once understood, effective measures can be developed. Florence Nightingale's Notes on Hospitals (1858) was the first publication to highlight the substantial risks arising from the built environment that affected patient outcomes. AMR represents a double-edged sword: while multi-drug-resistant organisms (MDROs) cause devastating, untreatable infections, they also act as visible markers within the healthcare built environment, revealing previously unrecognised sources and transmission pathways. National AMR action plans in healthcare, despite years of implementation, have not resolved the problem. The growing body of evidence implicating the built environment in AMR transmission has yet to be reflected in mainstream training or national guidance. Standard infection prevention and control (IPC) practices may prove insufficient when transmission stems from a persistent environmental reservoir such as MDRO outbreaks from wastewater, requiring new solutions such as 'water-safe' care. Unwarranted practices that promote transmission of pathogens can be prevented by proper design that guides healthcare workers and minimises ongoing training costs. The article's proposed strategies provide a translational bridge to accompany the UK's new five-year AMR action plan. This integrated approach offers a pathway not only to preserve the efficacy of existing antimicrobials but also to protect future antibiotic agents, fundamentally reshaping the ongoing 'arms race' between microbes and pharmaceutical innovation. Addressing this gap requires a multi-disciplinary approach. Within IPC, it is essential that the emerging knowledge about environmental transmission is formally recognised and incorporated into dedicated training and specialised tools. It is time, once again, to update Notes on Hospitals - this time for the era of AMR.