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Reducing the impact of antimicrobial therapy is a part of fundamental practice for health care providers, pharmacists, microbiologists, and public health professionals. Inclusion of nurses in the conversation regarding actions and implementation to achieve this end has often been an afterthought.

However, the number of nurses practicing across every health care setting makes us critical and active partners. What, specifically, are the roles and actions of nurses in addressing antimicrobial resistance, antimicrobial stewardship (AMS), and safe patient care and outcomes? Let’s first review the basics of the problem.

Nursing Activities Relevant to Antimicrobial Use and Stewardship

The approximately 5.77 million active nurses in the United States are widely trusted and well positioned to provide education on antibiotic use and influence behavior related to antimicrobial therapy. Their universal presence in health care settings empowers them to play a role as frontline actors in antimicrobial stewardship across inpatient, outpatient, and community settings. To make this happen, programs supporting appropriate use require commitment from health care leadership, available expertise in antimicrobial drug use, regular performance evaluation, reporting of outcomes, and education of those involved in the process as well as of patients who receive treatment.

Nurses play fundamental roles in almost every aspect of antimicrobial use and are recognized as vital to stewardship teams through their work, including:

  • Monitoring and early detection: Nurses track infection signs and medication side effects such as rashes and diarrhea. By ensuring timely administration or discontinuation of antibiotics, they can reduce risk of antimicrobial resistance.
  • Dose and route management: Nurses prompt intravenous to oral switches and compliance with institutional guidelines based upon their assessment of patient conditions and activities.
  • Specimen collection: Timely and proper microbiology specimen collection (urine, respiratory, wound) is often nurse led.
  • Patient education: Nurses provide education to patients and families including information concerning when antibiotics are necessary, side effects, proper dosing, and implications of misuse.
  • Social services assistance: Patients often share information with their nurses, including social and economic situations that may affect their abilities to pay for/continue treatment, thereby placing nurses in important roles to facilitate connections with social workers and care coordinators.
  • Collaborative leadership: Health organizations such as the Centers for Disease Control and Prevention (CDC) and the American Nurses Association (ANA) lay out frameworks for formal nurse roles involving liaising with pharmacists, infection control teams, and health care providers including nurse practitioners and physicians.

Evidence supports that nurse-led stewardship can boost guideline adherence, enhance patient safety, reduce adverse events, and diminish antimicrobial resistance. Still, broader implementation requires consistent education, empowering policies, and organizational support.

A recent systematic review highlights the need for strategies that address both individual and organizational factors to successfully integrate AMS into nurses’ daily practice. On an individual level, competency-based education is crucial to guide nurses’ unique roles in clinical workflows and to reinforce their knowledge and understanding of AMS principles. At the organization level, intuitional policies and guidelines clearly defining nurses’ roles and responsibilities, promoting interdisciplinary collaboration, and involving nurses in stewardship rounds can increases their involvement in AMS efforts. Institutional mechanisms such as ongoing quality improvement systems, timely feedback, and incentives in line with stewardship objectives also are necessary to support these efforts. Some of these steps are outlined below.

Defining and Mainstreaming Nurses’ Roles in AMS

Nurses’ professional identities and capacity to collaborate effectively with other health care providers are strengthened when their roles in AMS are well defined and incorporated into institutional guidelines and policies. They oversee patient monitoring, antibiotic education, timely administration, and identifying stewardship cues like monitoring duration or initiating IV-to-oral transitions. By bringing expectations into line, this clarity not only increases nurses’ self-confidence and sense of responsibility but also enhances teamwork. Incorporating these responsibilities into policy frameworks empowers nurses in their AMS work and supports a shared, interdisciplinary vision of stewardship.

It’s not enough just to define and formalize nurses’ roles in AMS; everyone on the care team needs to recognize and support them too. Nurses contribute to stewardship efforts every day, and that work should be acknowledged by physicians, pharmacists, administrators, and others. When teams collaborate through shared governance, interprofessional rounds, or just plain open communication, nurses’ voices carry more weight. These interactions foster cross-disciplinary trust and help nurses’ stewardship involvement feel routine rather than exceptional. Such visibility is important. It reaffirms that nurses are crucial collaborators in making informed and smart choices regarding the use of antibiotics.

Clinical competence determines how well nurses could contribute to AMS. Nurses are better equipped to participate in stewardship decisions when they receive targeted training in microbiology, pharmacology, diagnostics, and infection control. These abilities enable nurses to assess lab results, assess the appropriateness of antibiotic therapy, and identify opportunities for intervention, such as voicing concerns about inappropriate prescribing. It has been demonstrated that structured educational programs, in both pre-licensure and continuing education settings, enhance nurses’ confidence and stewardship behaviors. Incorporating AMS concepts into standard nursing curricula and practice settings enhances the profession’s capacity to lead and innovate within stewardship frameworks.

Research shows that nurses’ knowledge, attitudes, and adherence to best practices are greatly improved when they receive timely and pertinent feedback on their AMS contributions. By incorporating feedback loops into regular stewardship tasks, nurses can make better contributions that are informed by data and guided by collaborative learning. 

Action Items for Nurses

There are some specific actions nurses can take as part of this battle:

  • Consistently apply and promote infection prevention and control core competencies (hand hygiene, selection and use of personal protective equipment, safe care of indwelling devices, environmental infection control).
  • When providing care, make sure you are aware of the reasons antibiotics are currently being administered to a patient in your care. Develop care-related activities targeting that infection (such as surgical wound care, pulmonary hygiene).
  • Adhere to antimicrobial administration schedules, minimizing late or missed doses.
  • Perform testing activities to ensure ideal specimen collection to prevent contamination of blood cultures.
  • Provide patient education targeting reasons for antibiotic prescriptions, promoting appropriate administration schedules, addressing barriers to initiation and completion of antibiotic courses.  Include basic information regarding antimicrobial resistance as the ‘why’ behind appropriate use of antibiotics. Tailor the education to the learning abilities of the patient.
  • Encourage clear documentation of the purpose and duration of antibiotic administration, particularly during the initial course of treatment. This facilitates follow-up and keeps everyone on the same page, particularly when antibiotics should be stopped (negative blood culture) or de-escalated (for example, treatment and patient progress indicates an ability to switch from IV to oral administration).
  • Take part in “antibiotic timeouts” every 48 to 72 hours to determine whether the antibiotic is still required or if it can be modified or discontinued. Nurses are frequently the first to notice minor side effects or signs of improvement, so ensure there are abilities to share those observations with providers.
  • Open communication and discussion with providers so there is an ability to keep track of the total number of days a patient is on antibiotics, including both hospital days and discharge prescriptions, in order to prevent taking antibiotics for longer than necessary.
  • Recognize and report adverse effects, such as diarrhea, rashes, or anything that does not seem right. Since nurses are typically the first to notice these issues, flagging them early can have a significant impact.
  • Seek ongoing education regarding antibiotic resistance and stewardship. This knowledge extends beyond patient care and may also impact care and safety of those within nurses’ families who are also prescribed antimicrobials.

Nurses are integral to antimicrobial stewardship. Their roles in monitoring, administration, specimen collection, education, and multidisciplinary collaboration ensure safer, more effective antibiotic use. With strong public trust and growing recognition from institutions like the CDC and ANA, nursing is positioned to lead AMS efforts, reduce resistance, and improve patient outcomes. However, to harness this potential fully, investment in nurse education, stewardship policies, and system support is essential.

References

Fishman, N. (2006). Antimicrobial stewardship. American journal of infection control, 34(5), S55-S63.

Olans, R. N., Olans, R. D., & DeMaria Jr, A. (2016). The critical role of the staff nurse in antimicrobial stewardship—unrecognized, but already there. Clinical Infectious Diseases, 62(1), 84-89.

Camerini, F.G., Cunha, T.L., Fassarella, C.S. et al. Nursing strategies in antimicrobial stewardship in the hospital environment: a qualitative systematic review. BMC Nurs 23, 147 (2024). https://doi.org/10.1186/s12912-024-01753-y

 

Ruth Carrico, PhD, FNP-C, CIC, FSHEA, FNAP, FAAN
Adjunct Professor
Division of Infectious Diseases
University of Louisville School of Medicine
Louisville, KY

Aravind Pillai, PhD, MBBS, MPH
Epidemiologist III
Antibiotic Stewardship Lead
Kentucky Department for Public Health
Infectious Disease Branch
Healthcare Associated Infection Prevention Program (HAI Program)
Frankfort, KY