Antimicrobial stewardship: A nursing imperative across all healthcare settings

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Reference: January-February 2025 | Issue 1 | Vol 19 | Page 58

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Nurses are ideally positioned to lead, support, and sustain antimicrobial stewardship activities

Antimicrobial resistance (AMR) is widely recognised as one of the most serious threats to global health. As once-reliable anti-microbial treatments become less effective, the management of common infections becomes more complex, and vulnerable patients face increased risks of prolonged illness, complications, and poorer outcomes.

The misuse and overuse of antimicrobials in hospitals, community care, long-term care, and outpatient settings are major contributors to this crisis.¹ More than 35,000 people die each year due to antibiotic resistance across Europe.²

According to the World Health Organisation 2025 Global Antibiotic Resistance Surveillance Report, one-in-six laboratory confirmed bacterial infections worldwide in 2023 were resistant to standard antibiotic treatments, highlighting the urgent global need for robust antimicrobial stewardship (AMS) practices in all care settings.¹

Nurses are ideally positioned to lead, support, and sustain AMS activities. Their engagement is important in safeguarding the effectiveness of antimicrobial therapy, optimising patient outcomes, and contributing to the reduction of AMR.^2,3

In recognition of the urgent need to curb AMR, the HSE in Ireland developed the Antimicrobial Resistance and Infection Control (AMRIC) 2022-2025 guidance, which sets out a national framework for strengthening AMS across all areas of healthcare.

This guidance highlights the scale of the challenge and reinforces that effective stewardship must extend beyond prescribing decisions alone. It calls for a whole system, coordinated approach that integrates clinical, organisational, and public health strategies to reduce inappropriate antimicrobial use and improve infection prevention and control.^3,4

AMRIC emphasises that AMS is not solely the responsibility of prescribers. Instead, it requires active engagement from the entire healthcare workforce, including pharmacy, microbiology, infection prevention specialists, healthcare assistants, and organisational leadership.

Within this multidisciplinary model, nurses are positioned as central contributors given their continuous patient contact, pivotal role in assessment and monitoring, and capacity to influence prescribing decisions through early recognition of infection, advocacy for timely review of antimicrobial therapy, and adherence to evidence-based care pathways.

As frontline clinicians, nurses are uniquely placed to support safe prescribing practices, promote patient education, and ensure that stewardship principles are embedded into everyday care.^3,4

AMS is defined as a coordinated set of interventions designed to optimise the use of antimicrobial medications, ensuring that patients receive the appropriate agent, dose, route, and duration of therapy while minimising unnecessary use, toxicity, and resistance.^3,4

In practice, AMS encompasses activities that span patient assessment, appropriate prescribing, administration, monitoring, infection prevention, education, and evaluation of antimicrobial use.

In Ireland, the majority of antibiotic use occurs outside hospital settings, in community care, residential facilities, and outpatient clinics. These environments often lack the robust AMS oversight found in hospitals, making them particularly important targets for stewardship initiatives.⁵

Nurses, who routinely engage in triage, assessment, specimen collection, administration, patient education, monitoring, and care coordination, are uniquely positioned to influence antimicrobial use positively. Across acute, community, and long-term care settings, nurses are often the first and most frequent point of contact for patients, giving them the opportunity to implement evidence-based stewardship interventions effectively.^4,5

Nursing-led AMS: Challenges and solutions

Despite their central role, nurses encounter several barriers to effective stewardship. These include lack of formal AMS education, unclear role definition, time pressures, high workload, and limited access to diagnostic resources. In some cases, cultural expectations from patients or colleagues may create pressure to prescribe antimicrobials, even when not clinically indicated.

Resource limitations are particularly pronounced in long-term care and community settings, where staffing constraints, high patient turnover, and limited laboratory access can impede evidence-based decision-making. Overcoming these challenges requires institutional commitment, multidisciplinary collaboration, and inclusion of nurses in policy and governance structures.^1,4

Approximately 80 per cent of antibiotic prescribing in Ireland is conducted in general practice.⁶ Patient demands, expectation, familiarity with the clinician, and time restraints have been documented as key factors for overprescribing antibiotic therapy in general practice, despite clinical evidence suggesting when it is not necessary.⁷

Efforts to reduce unnecessary antibiotic prescribing in Ireland include education and training for prescribing healthcare professionals; implementing decision support tools; using point of-care testing including C-reactive protein; and supporting evidence-based practice through audit and evaluation. Initiatives also promote delayed prescribing where possible, evaluating its effectiveness, identifying barriers, and enhanced adoption through behavioural science approaches.⁷

All prescribing healthcare professionals have an ethical responsibility to prescribe antibiotics judiciously to reduce the risk of resistance.⁸ This requires a comprehensive understanding of the core principles of antibiotic selection, including the underlying pathology, and the therapeutic characteristics of the prescribed agents, ensuring that treatment is evidence-based, safe, and cost-efficient.⁹

Ethical practice also includes a commitment to AMS and the responsibility to effectively communicate with and educate patients when antibiotics are not indicated.⁷ Practice standards, decision-making frameworks, clinical governance structures, and the regulatory body outline the criteria for safe and effective nurse prescribing practice.

Good prescribing practice should optimise patient outcomes, support patient care, and encourage treatment concordance and adherence, while considering clinical response, tolerability, and lifestyle factors. Patients should be included in clinical decision-making processes, informing them of available options, while ensuring that prescriptive practice is safe, evidence-based, appropriate and in the patient’s best interest.^9,10

Multiple studies have demonstrated that nurses contribute meaningfully to AMS outcomes. A scoping review examining nurse-led AMS activities in hospitals found that nurses are central to identifying patients with infections, administering and monitoring antimicrobial therapy, collecting high-quality specimens, educating patients and families, and participating in policy development and quality improvement initiatives.¹¹ These interventions have been associated with reduced inappropriate antimicrobial use, lower rates of adverse drug events, and improved adherence to local and national guidelines.

In addition to hospital settings, nurses in long-term care, community services, and primary care are key stewards. A recent survey highlighted that nurses perceive themselves as advocates for appropriate antimicrobial use, educating patients and carers, monitoring therapy, and communicating critical clinical information to prescribers.

However, many nurses report feeling underutilised in stewardship decision-making, despite their frontline role in patient care.^11,12 International literature supports this view, indicating that AMS programmes that incorporate nursing leadership or structured nursing input achieve better adherence to guidelines, more appropriate antimicrobial use, and improved patient outcomes.¹²

The HSE Medicines Management Programme, working in partnership with the AMRIC team, introduced a national preferred antibiotics initiative, commonly referred to as the green/red antibiotic list. This initiative forms a key component of Ireland’s national AMS strategy and aims to standardise antimicrobial prescribing across primary and community care.

By clearly identifying preferred first-line ‘green’ antibiotics, the system guides clinicians toward agents that are effective for common infections, have favourable safety profiles, and present a lower selective pressure for the development of antimicrobial resistance. This approach not only supports safer, evidence-based prescribing, but also reduces unwarranted variation in clinical practice.^5,13

The initiative is strengthened by the HSE AMRIC community antimicrobial prescribing guidelines, available at: www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/, which provide detailed, condition-specific recommendations to support prescribers in choosing the most appropriate antimicrobial therapy.

These guidelines outline when preferred ‘green’ antibiotics should be used, the clinical indications they cover, optimal duration of therapy, and when alternative agents may be required. Equally important, the guidance highlights circumstances in which ‘red’ antibiotics should be avoided unless there is a clear, evidence-based rationale for their use, typically due to their broader spectrum, higher risk of adverse events, or greater potential to drive resistance.

Together, the preferred antibiotics list and accompanying guidelines promote consistency, improve patient safety, and help ensure that antimicrobial use in the community is appropriate, targeted, and aligned with national stewardship priorities.^5,13

ANPs and RNPs

Advanced nurse practitioners (ANPs) and registered nurse prescribers (RNPs) play a leading role in AMS, not only through their prescriptive authority, but also through their influence on patient understanding and expectations.^9,10

They are strategically positioned to reduce unnecessary antibiotic prescriptions by applying evidence-based assessment, diagnostic reasoning, and therapeutic decision-making. A key component of this role involves challenging the common misconception that antibiotics provide a ‘quick fix’ for all infections.

By fostering realistic treatment expectations, ANPs and RNPs encourage patients to consider non-antibiotic management strategies for self-limiting conditions, thereby reducing inappropriate antimicrobial use and limiting the selection pressure that drives resistance.^8,14

The issue of antibiotic resistance continues to escalate globally, representing a major threat to public health and healthcare systems.¹ The careful selection of empirical therapy guided by up-to-date local resistance patterns is essential to ensure both treatment efficacy and the preservation of antimicrobial effectiveness for future patients.^9,10

ANPs and RNPs contribute to this process by integrating local epidemiological data, guideline recommendations, and individual patient factors into their prescribing decisions.⁵ Their consistent application of stewardship principles across settings, from primary care and community clinics to acute care hospitals, ensures a coordinated approach to responsible antibiotic use.

In addition to their clinical responsibilities, ANPs and RNPs play a central role as educators and advocates for AMS within the community. They deliver patient-centred guidance on the risks of inappropriate antimicrobial use, including adverse drug reactions, the emergence of resistant pathogens, and the increased likelihood of treatment failure.

By providing clear, accessible information, ANPs and RNPs help patients understand the importance of completing prescribed courses, adhering to recommended dosing, and recognising when antibiotics are not indicated, such as for viral infections.¹⁴

Education initiatives led by nursing professionals may take multiple forms, ranging from one-on-one consultations and personalised advice during clinical encounters to broader public health campaigns aimed at raising community awareness.

Nurses also engage in collaborative efforts with other healthcare providers, including general practitioners, pharmacists, and allied health staff, to standardise messaging, reinforce consistent stewardship principles, and ensure that communication around antibiotic use is evidence-based and culturally appropriate.

Through these multifaceted educational roles, ANPs and RNPs not only enhance patient knowledge and empowerment, but also directly contribute to reducing inappropriate antimicrobial use and slowing the progression of resistance at the community level.¹⁴

There are significant opportunities for research and innovation in nursing-led stewardship. Future studies could explore strategies aimed at addressing patient expectations for antibiotics in cases where they are clinically unnecessary. This research may include evaluating the effectiveness of structured communication frameworks, shared decision-making models, and behavioural interventions designed to reduce inappropriate prescribing.

It is equally important to consider the psychological, cultural, and social factors that influence both patient demand and clinician prescribing behaviours. Understanding these influences can inform the development of tailored interventions that support ANPs and RNPs in making judicious prescribing decisions while maintaining patient satisfaction and trust.

By combining clinical expertise with a focus on education, communication, and behaviour change, ANPs and RNPs are integral to the ongoing effort to curb antimicrobial resistance and promote sustainable prescribing practices.

Conclusion

AMS is a shared responsibility that extends across all healthcare disciplines and settings. Nurses, by virtue of their central and continuous involvement in patient care, are uniquely positioned to lead, support, and embed stewardship initiatives. In Ireland, the HSE AMRIC guidance recognises this potential and advocates for comprehensive, multi-setting implementation of AMS practices.

Through active engagement in patient assessment, specimen management, administration and monitoring, patient education, infection prevention, audit, and multidisciplinary collaboration, nurses can ensure that antimicrobial therapy is safe, effective, and appropriate.

Formalising nursing roles in stewardship, providing education, and embedding AMS into daily practice will enhance patient outcomes, preserve antimicrobial efficacy, and contribute to the national and global fight against antimicrobial resistance. Nurses are not only caregivers, they are stewards of one of medicine’s most precious resources, and their leadership is critical for sustainable antimicrobial use.