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Redefining the Antibiotic Stewardship Team:
Recommendations from the American Nurses
Association/Centers for Disease Control and Prevention
Workgroup on the Role of Registered Nurses in Hospital
Antibiotic Stewardship Practices
Effective Date: 2017
Executive Summary
The purpose of this American Nurses Association/Centers for Disease Control and Prevention (ANA/CDC)
White Paper is to inform registered nurses in the United States about the problem of antibiotic resistance
and facilitate their embracing an expanded and clearly recognized role in hospital antibiotic stewardship
programs (ASPs) and activities. The White Paper is the result of a
series of online meetings, culminating in a one-day live
conference with a selection of nurses identified by ANA and CDC
as having expertise and/or interest in antibiotic stewardship. The
purpose of the workgroup is to explore how nurses can become
more engaged and take a leadership role to enhance our nation’s
antibiotic stewardship efforts. The first part of the White Paper
reviews ASPs and the current state of antibiotic resistance. The
second section is a summary of the workgroup’s discussions on current barriers to full nurse participation in
ASPs; gaps in nurses’ knowledge and education about antibiotic stewardship; and the use of antibiotics in
the 21
st
century. The third part explores opportunities for nurses to add their expertise to our nation’s
ongoing stewardship efforts and offers recommendations for future nursing education.
While often used interchangeably,
the terms “antibiotic” and
“antimicrobial” are not the same.
Microbes include bacteria, viruses,
fungi, and parasites;
antimicrobials are agents against
any of these. Antibiotics are agents
that specifically target bacteria.
1
The mark ‘CDC’ is owned by the US Department of Health and Human Services (HHS) and is used with
permission. Use of this logo is not an endorsement by HHS or CDC of any particular product, service,
or enterprise.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
While this White Paper is neither a formal nor a complete roadmap, it does succinctly outline the group’s
ongoing efforts to place the nation’s 3.6 million nurses in central roles in antibiotic stewardship efforts.
Part I
Introduction
The need to improve antibiotic use is fundamentally a patient safety issue. Like all medications, antibiotics
have side effects. Patients exposed to antibiotics can develop a variety of adverse drug reactions specific to
individual agents, such as nephrotoxicity. However, patients exposed to antibiotics are also at risk for a
variety of unique adverse reactions due to the antibacterial effects of the drugs, which can indiscriminately
alter a patient’s bacterial population (known as the microbiome). This disruption is known to increase risks
for diarrhea, including a diarrheal super-infection caused by Clostridium (C.) difficile, which can be serious
and even fatal. Moreover, there is growing evidence that disruption of the microbiome can lead to other
serious adverse outcomes, such as sepsis.
2
When patients have serious bacterial infections, like sepsis, the
benefits of prompt antibiotic therapy outweigh the risks. However, when patients get antibiotics they do not
need, they are put at risk for totally avoidable adverse reactions. Unfortunately, many studies done in every
practice setting have shown that antibiotics are often used when they are not needed.
Exposure to antibiotics also poses the additional risk of antibiotic resistance. This makes antibiotics unique in
that their effectiveness wanes over time because bacteria inevitably develop resistance to them. Over the
past several decades, antibiotic resistance has increased and spread dramatically throughout the world. The
loss of effective antibiotic therapy jeopardizes not only the health of patients with infections, but also the
capacity to safely deliver other medical care. Medical advances such as complex surgery, organ transplants,
and chemotherapy are largely dependent on antibiotics to both prevent and treat common infectious
complications. The threat of antibiotic resistance is compounded by the fact that it can be passed from one
bacterium to another, and that antibiotic-resistant bacteria themselves can be spread from person to
person. Therefore, the overuse and misuse of antibiotics not only have implications for the individual
patient, but also for population and societal health.
The CDC report, Antibiotic Resistance Threats in the United States, 2013, provided the first comprehensive
snapshot of the problem. Using conservative estimates, the CDC figured that each year more than two
million Americans develop serious infections with bacteria that are resistant to one or more antibiotics, and
at least 23,000 people die each year as a direct result of these infections.
3
According to the CDC report,
improving antibiotic use is one of the most important needs in reducing antibiotic resistance.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
CDC Core Elements of Hospital
Antibiotic Stewardship Programs
• Leadership Commitment:
Dedicating necessary human,
financial, and information
technology resources
• Accountability: Appointing a
single leader responsible for
program outcomes – experience
with successful programs shows
that a physician leader is
effective
• Drug Expertise: Appointing a
single pharmacist leader
responsible for working to
improve antibiotic use
• Action: Implementing at least
one recommended action, such as
systemic evaluation of ongoing
treatment need after a set period
of initial treatment (i.e.,
“antibiotic time out” after
48 hours)
• Tracking: Monitoring antibiotic
prescribing and resistance
patterns
• Reporting: Regular reporting
information on antibiotic use and
resistance to doctors, nurses, and
relevant staff
• Education: Educating clinicians
about resistance and optimal
prescribing
Antibiotic prescribing in US acute care hospitals is common and often
unwarranted. As many as half of hospitalized patients receive at least
one antibiotic and in up to 50 percent of these patients, antibiotics are
unnecessary or inappropriate.
4
Such antibiotic misuse contributes not
only to adverse drug reactions, like C. difficile, but to the emergence of
antibiotic-resistant organisms, such as methicillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci
(VRE), and carbapenem-resistant Enterobacteriaceae (CRE).
5
Most
registered nurses are already aware that C. difficile infections are a
major problem, spreading not only in hospitals but in outpatient and
community settings as well. C. difficile has become the most common
cause of health care-associated infections in US hospitals, and the
excess health care costs related to C. difficile infection are estimated to
be as much as $4.8 billion for acute care facilities alone.
6
In fact, C.
difficile causes almost half a million infections annually, and an
estimated 83,000 of the patients with such infections have at least one
recurrence. Moreover, approximately 29,000 die within 30 days after
the initial diagnosis.
7
Given the high morbidity, mortality, and human and economic costs, in
conjunction with a decline in discovery and development of new
antibiotics, antibiotic resistance has been identified as one of the most
serious threats to health in the United States and has led to the
development of the National Action Plan for Combating Antibiotic-
Resistant Bacteria.
8
Part of this national imperative is the
implementation of ASPs in all acute care hospitals by 2020.
Antibiotic Stewardship
In a consensus statement from the Infectious Diseases Society of America (IDSA), the Society for Healthcare
Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society, antibiotic stewardship has
been defined as “coordinated interventions designed to improve and measure the appropriate use of
[antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen, including dosing,
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
duration of therapy, and route of administration.”
9
A growing body of evidence supports formalized stewardship programs as a viable avenue to decrease
unnecessary exposure to antibiotics, improve infection cure rates, reduce adverse drug reactions, and slow
the emergence of antibiotic resistance, with resultant significant cost savings for hospitals.
To help hospitals implement ASPs, the CDC developed in 2014 the Core Elements of Hospital Antibiotic
Stewardship Programs, outlining seven components that have been linked with successful ASPs.
10
The CDC
core elements call for a multidisciplinary approach to improving antibiotic use. And as of January 2017, The
Joint Commission is also requiring hospital ASPs to demonstrate inter-professional engagement to address
core performance elements and expand antibiotic stewardship reach.
11
Both CDC and The Joint Commission
specifically highlight the need to engage nurses as part of the multidisciplinary effort. Moreover, the central
role nurses can play in hospital quality improvement has been well documented in efforts such as bundle
implementation for the prevention of central line-associated blood stream infections (CLABSI) and nurse-
directed catheter removal for prevention of catheter-related urinary tract infections (CAUTI).
12,17,18
Yet,
despite these and other recommendations to include bedside nurses in stewardship development, efforts to
engage nurses in antibiotic stewardship have been limited.
19
In response to the critical need to expand antibiotic stewardship and in recognition of the central role that
nurses play in patient care and quality improvement, CDC (with a grant from the CDC Foundation) partnered
with ANA to bring together a group of registered nurses to explore the nurse role in acute care hospital
ASPs, and to identify practical and feasible areas for nurse engagement.
Part II
ANA/CDC Antibiotic Stewardship Workgroup
Capturing the work of registered nurses is crucial to demonstrating the value of nursing in ASPs. Figure 1
shows the position of the nurse with patient and family at the hub of communication among all of the
stakeholders in antibiotic use. This central role puts nurses in a unique and vital position in optimizing
antibiotic use. In the annual Gallup poll on honesty and ethics, nursing is overwhelmingly viewed by the
American public as the most trusted profession.
13
Nurses are in the hospital, in the home, and in the
community. As such, they can be educators, advocates, and ambassadors for widespread behavioral change
to more vigilant antibiotic awareness in our society.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
In late 2015, ANA sent out a call to members soliciting interest in working with CDC and ANA to better
define and expand the role of bedside nurses in antibiotic stewardship efforts in acute care hospitals. From
these applications, staff at CDC and ANA selected about 30 members to serve on an expert advisory
committee. Members were chosen to represent a diversity of geographic locations, expertise, and acute
care hospital settings. The workgroup held a series of virtual meetings, culminating in a one-day live seminar
in July 2016 at ANA headquarters in Silver Spring, MD.
Literature and Practice Review
To create a baseline from which to launch the antibiotic stewardship discussion, workgroup participants
reviewed several relevant articles. In the first paper, The Critical Role of the Staff Nurse in Antimicrobial
Stewardship—Unrecognized, but Already There, Olans, Olans, and DeMaria discuss how, although the
registered nurse role has not been formally recognized in guidelines for implementing and operating ASPs or
defined in the peer-reviewed literature, nurses have always performed numerous functions that are integral
to successful antibiotic stewardship.
12
The paper provides a helpful table showing the overlap of what could
be considered nursing antibiotic stewardship activities, with the traditionally identified activity stakeholder
(e.g., infectious disease physician, pharmacist) who is usually assigned responsibility. In a related paper,
Olans, Nicholas, Hanley, and DeMaria document that nurses recognize their educational gaps regarding both
antibiotic use and antimicrobial stewardship.
14
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
Those educational needs apply both to nurses in training as well as to nurses already in clinical practice to
enable the successful integration of nurses into current antimicrobial stewardship activities.
19
The workgroup emphasized that there are many areas where nursing and ASP functions already overlap. The
tables below illustrate the variety of nursing antibiotic functions that coincide with existing antibiotic
stewardship goals.
Table 1: Antimicrobial Stewardship Functions Performed by Nurses
Stewardship Activity
or Task
CDC Core Stewardship
Element
Unrecognized Nurse
Role in
Stewardship Functions
Appropriate triage and
isolation
Accountability
Drug Expertise
Education
The nurse initially
assesses the source of
infection and identifies
appropriate
precautions.
Consultation may come
subsequently from the
infection preventionist.
Accurate antibiotic
allergy history
Accountability
Drug Expertise
Education
The nurse takes the
allergy history,
performs medication
reconciliation, and
records this in the
medical record.
Early and appropriate
cultures
Accountability
Drug Expertise
Tracking
The nurse obtains the
cultures before starting
antibiotics and sends
the cultures to the
microbiology
laboratory. The nurse
monitors the culture
results and reports
results to the physician.
Timely antibiotic
initiation
Drug Expertise
Action
Tracking
The nurse receives the
orders, reviews
dose/time for accuracy,
checks for allergy, and
administers and
records the antibiotics.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
Table 2: Clinical Progress & Patient Safety Monitoring
Stewardship Activity or
Task
CDC Core Stewardship
Element
Role Responsible in
Current ASP Models
Unrecognized Nurse Role
in Stewardship Functions
Progress reporting
Drug Expertise
Action
Tracking
Hospitalist
Infectious Disease
Specialist
The nurse cares for the
patient 24/7, and
monitors and
communicates daily
patient progress.
Antibiotic
adjustment based on
microbiology reports
Drug Expertise
Action
Tracking
Hospitalist
Infectious Disease
Specialist
Microbiologist
Laboratory and radiology
reports “chase” the
patient and are typically
received first by the
bedside nurse. Results are
coordinated by the nurse
and communicated to
treating physicians.
Antibiotic dosing, culture
and sensitivity reporting,
and
de-escalation
Drug Expertise
Action
Tracking
Education
Infectious Disease
Specialist
Microbiologist
Pharmacist
The nurse updates clinical
and laboratory renal
function results, drug
levels, and
preliminary/final
microbiology results.
Adverse events
Action
Tracking
Education
Hospitalist
Pharmacist
The nurse monitors and
reports to the physician
and pharmacist any
adverse events including
diarrhea.
Antibiotic orders
Drug Expertise
Action
Tracking
Education
Hospitalist
Infectious Disease
Specialist
The nurse reviews the
patient’s clinical status
and changes in
medications.
Antibiotic resistance
Drug Expertise
Action
Tracking
Education
Infectious Disease
Specialist
Hospitalist
Microbiologist
The nurse reviews culture
and sensitivity results, and
reports bug/drug
mismatches, time outs,
and antibiotic de-
escalation.
Superinfection /
resistant infection
Action
Tracking
Education
Infectious Disease
Specialist
Infection Preventionist
Microbiologist
The nurse monitors
patient response and
initiates appropriate
changes in isolation
precautions.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
Table 3: Discharge
Stewardship Activity or
Task
CDC Core Stewardship
Element
Role Responsible in
Current ASP Models
Unrecognized Nurse Role
in
Stewardship Functions
Transition IV-to-PO
antibiotic,
outpatient antibiotic
therapy
Drug Expertise
Action
Tracking
Education
Case Management
Infectious Disease
Specialist
Pharmacist
The nurse monitors
clinical progress and the
patient’s capacity to take
oral medications.
Length of stay
Action
Tracking
Education
Administration
Case Management
Infectious Disease
Specialist
The nurse monitors the
patient’s progress 24/7.
Patient education,
medication
reconciliation
Drug Expertise
Action
Education
Hospitalist
Infectious Disease
Specialist
Pharmacist
The nurse continuously
educates the patient and
family, and performs
discharge teaching.
Outpatient visiting nurse
association (VNA)/skilled
nursing facility
(SNF)/long-term care
facility (LTCF) transition
management,
re-admission to hospital
Action
Tracking
Education
Administration
Case Management
Infection Preventionist
The nurse communicates
the patient’s diagnosis,
management, and
medications to the nurse
at the VNA/ SNF/LTCF.
Adapted with permission from Olans RD, et al. (2017). Good nursing is good antibiotic stewardship. American Journal of
Nursing, 117(8), 58-63.
Workgroup members considered the CDC’s Infection Prevention and Control Assessment Tool for Acute Care
Hospitals.
15
Divided into four sections, the tool is intended to assist acute care hospitals in the assessment of
infection control programs and practices, to include: facility demographics; current facility infection control
infrastructure; facility guidelines and other resources; and an optional onsite observation of facility
practices. Of note, the assessment tool’s Infection Control Program and Infrastructure checklist has specific
focus on “Systems to Detect, Prevent, and Respond to Healthcare-Associated Infections and Multidrug-
Resistant Organisms,”
15
which include ASPs.
Workgroup members also reviewed the role of the nurse executive in antibiotic stewardship as outlined in
Manning and Giannuzzi’s article Keeping Patients Safe. In order for bedside nurses to fully engage in ASPs,
and demonstrate the value of nursing in ASPs, they need full support of nursing leadership. The authors
argue that nurse executives play a central role in spearheading strategic nursing engagement in institutional
programs that keep patients safe. In such a role, nurse executives are in a prime position to influence ASPs.
16
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
Suggestions from the Workgroup
The workgroup identified four key questions and developed suggestions to address each of them.
What are the roles that bedside nurses can and should play in working to improve antibiotic use?
Obtain appropriate cultures, using proper technique, before antibiotics are started. Understand how
the microbiology laboratory processes those samples.
Use microbiology results to help guide the optimal selection of antibiotics and guide decisions to
stop therapy in cases where culture results represent colonization, rather than infection.
Help inform decisions to start antibiotics promptly at the time early signs of likely bacterial
infections, including sepsis, are identified.
Help ensure that practices to ensure good antibiotic use are embedded in other quality
improvement efforts. For example, for sepsis, help ensure that antibiotics are started promptly and
then reviewed once additional data, especially cultures, are available.
• Prompt, and participate in, discussions about antimicrobial usage including antibiotic de-escalation
by evaluating each patient’s clinical status and readiness for change from intravenous to oral
therapy, when possible.
• Take a more detailed allergy history, especially around penicillin allergy. Help educate patients and
families about what constitutes an accurate antibiotic allergy history.
What education and training resources are needed to help nurses perform these roles?
• Microbiology education and training on how to both obtain cultures and interpret the results.
• Education about infection versus colonization.
• Assertiveness training to engage in discussions with the health care team.
• Information on IV-PO switch criteria.
• Training on taking an allergy history.
How can we engage nurses more and encourage them to participate in antimicrobial stewardship
programs?
At the national level:
• Explore avenues to have nurse engagement in ASPs included in American Nurses Credentialing
Center (ANCC) Magnet Recognition Program® criteria.
• Use The Joint Commission’s Medication Management standard and proposed Centers for Medicare
and Medicaid Services Condition(s) of Participation on antimicrobial stewardship to guide nurse-
relevant antibiotic stewardship tools and products.
Bring stewardship issues to national stakeholder meetings.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
• Add stewardship content to priorities for publication in nursing journals.
Encourage nursing schools to integrate antibiotic stewardship concepts into currently required
microbiology, pharmacology, and applied clinical education.
Develop antibiotic stewardship content specific to unique specialties, e.g., oncology nursing.
At the hospital level:
Provide antibiotic stewardship education for bedside nurses. This could be provided by nurses
already engaged in stewardship activities, infectious disease physicians, pharmacists, infection
preventionists, or microbiologists.
• Include nurses in stewardship rounds.
• Participate in journal clubs.
Develop specific content and messages for nurses as part of any hospital effort to raise awareness
about antibiotic use and resistance.
• Encourage nurse antibiotic stewardship champions at the unit level.
What can we do to engage nursing leaders in stewardship efforts?
Highlight the fact that nursing involvement in antibiotic stewardship is required by The Joint
Commission.
Make hospital leadership aware that the Centers for Medicare and Medicaid Services has proposed
making ASPs a Condition of Participation for acute care hospitals.
Emphasize antibiotic stewardship as a key component of patient safety.
Highlight the benefits of good antibiotic stewardship on nursing workload. For example, better IV-
to-PO conversion will reduce time spent on medication administration.
Add measures related to antibiotic use, like C. difficile infection, to Magnet Recognition Program
criteria.
Knowledge Gaps
Workgroup members identified the following knowledge gaps, which present challenges to nurse
involvement in stewardship efforts. First, nurses may be unfamiliar with the concept of antimicrobial
stewardship. Second, nurses may be insecure about their knowledge of microbiology and antibiotic use.
Third, nurses may believe that antimicrobial stewardship is not their function because they do not perceive
themselves as antibiotic prescribers. Lastly, there is a lack of metrics that quantify nurses’ impact on
stewardship efforts.
As outlined in the articles the workgroup reviewed, nurses are essentially unacquainted with the phrase
“antimicrobial stewardship.” Such unfamiliarity is not surprising given limited efforts to engage nurses in
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
ASPs. The narrow discussion of antimicrobial stewardship in nursing literature also contributes to this
problem.
12, 14
Workgroup members also felt that the current approach to microbiology and pharmacology education could
be revisited to improve nursing engagement in stewardship. Many nursing schools deliver this content in a
theoretical framework without discussion of how microbiology and pharmacology data can be applied to
improve patient care. The workgroup would like to see this knowledge presented as an applied science
whose relevance and application for nurses is regularly reinforced in their subsequent clinical practice.
Under this model, microbiology and pharmacology principles that are the foundation of antibiotic
stewardship would seem less divorced from the daily care of patients. Likewise, the workgroup felt that the
challenges of antimicrobial resistance and the threat it poses to patient care need to be emphasized more in
nursing schools.
Some specific suggestions for education included:
Microbiology
How specimens for microbiology testing should be obtained;
How to interpret microbiology test results, especially susceptibility reports;
How to interpret the hospital antibiogram; and
Basics of distinguishing asymptomatic bacteriuria from urinary tract infection and colonization
from active infection.
Pharmacology
Considerations for IV-to-PO conversion: what antibiotics and patients are good candidates;
General information on antimicrobial spectra for various classes of antibiotics;
Antibiotic interactions and incompatibilities;
Common adverse reactions to antibiotics, with a special emphasis on recognizing and
responding to suspected C. difficile infections;
Information on therapeutic drug monitoring; and
How to assess a patient for a potential allergy to penicillin.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
Lack of Accepted Metrics to Quantify the Impact of Nurses’ Work in
Stewardship Activities
Evaluating nursing impact on antibiotic use should be part of the overall measurement approach of the ASP.
Stewardship programs are encouraged to monitor outcomes like antibiotic use, C. difficile infections, and
antibiotic resistance, and the impact of nursing interventions would be reflected in those outcomes. The
workgroup suggested that adding key outcome measures of antibiotic use, like C. difficile infection, as
measures in the ANCC Magnet Recognition Program could help drive more nursing engagement in
stewardship efforts.
There are also a variety of process measures that could directly assess nursing roles in stewardship. These
could include, for example, assessments of how often cultures are obtained before antibiotics are started,
and the frequency of nurse-initiated antibiotic discussions or “time outs.” In some hospitals, nurses are
playing an important role in recognizing patients with sepsis and initiating sepsis protocols. This could also
be an important stewardship measure since the early initiation of proper antibiotic therapy is a key goal of
stewardship programs. The workgroup agreed that more work needs to be done to better define the
optimal process measures for nursing stewardship interventions.
Incentivizing Hospitals to Address Nurse Antimicrobial Stewardship
Involvement
It is the natural progression to link nurses’ role in antimicrobial stewardship with Joint Commission
accreditation and Magnet® recognition. To that end, the ANA/CDC Workgroup proposed that the ANCC
Magnet Recognition Program endorse two clinical indicators, specifically as related to antibiotic
stewardship. MRSA and C. difficile will be added as optional unit- or clinic-level nursing-sensitive clinical
indicators in the 2019 Magnet Application Manual.
Part III
Recommendations: Major Areas the Workgroup Will Continue to Pursue
At the end of the July Conference, the ANA/CDC Workgroup outlined key areas for continued development
and advocacy:
• Develop and submit Magnet clinical indicators that promote engagement of nurses in stewardship
(action completed).
• Expand education with new understanding of when and how best to use antibiotics. This should be
made available to nursing students, to nurses in new-hire orientation, and as continuing education
for practicing nurses.
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
• Identify and develop outcome measurement tools to assess quality measures for nursing.
• Develop and distribute a position statement (this White Paper) to align nursing contributions with
those of other standardizing bodies, and with other infection and control prevention strategies and
quality improvement efforts, like sepsis management.
• Pursue ongoing communication and collaboration of ANA with other health care organizations
regarding optimal interdisciplinary antimicrobial stewardship activities.
The urgent need to improve appropriate, evidence-based antibiotic use cannot be overstated. With the
current worldwide expansion of multidrug-resistant organisms, the question is not whether to involve
nursing in antimicrobial stewardship, but how. An equally urgent need exists to engage nurses in front-line
ASPs, as well as patient education efforts. The background information and recommendations contained in
this White Paper provide an outline for strengthening the role of nurses in antibiotic stewardship. With an
estimated 3.6 million workforce, nurses represent a powerful voice and cohort by which to mold
interdisciplinary ASPs, enhancing patient safety and minimizing the spread of antibiotic resistance.
References
1
CDC. (2015, September 8). About Antimicrobial Resistance. Retrieved from:
https://www.cdc.gov/drugresistance/about.html
2
Baggs, J, Jernigan, J, McCormick, K, Epstein, L, Laufer-Halpin, LS, & McDonald, LC. (2016) Increased risk of
sepsis during hospital readmission following exposure to certain antibiotics during hospitalization. Open
Forum Infectious Diseases, 3(suppl_1): 73. doi: 10.1093/ofid/ofw194.08
3
CDC. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: US Department of Health and
Human Services, CDC. Available from: http://www.cdc.gov/drugresistance/threat-report-2013
4
Fridkin S, Baggs J, Fagan R, Magill S, Pollack LA, Malpiedi P, et al. (2014). Vital signs: improving antibiotic use
among hospitalized patients. MMWR Morbidity & Mortality Weekly Report, 63:194-200.
5
Marston, HD, Dixon, DD, Knisely JM, Palmore, TN, & Fauci, AS. (2016). Antimicrobial resistance. The JAMA
Network, 316(11):1193-1204. doi: 10.1001/jama.2016.11764
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Lessa, FC, Mu, Y, Bamberg, WM, Beldavs, ZG, Dumyati, GW, Dunn, JR, Farley, MM, …McDonald, LC, (2015).
Burden of Clostridium difficile infection in the United States. New England Journal of Medicine 372:825-34.
Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMoa1408913
7
CDC. CDC’s Top Ten: 5 Health Achievements in 2013 and 5 Health Threats in 2014. Available from:
http://blogs.cdc.gov/cdcworksforyou24-7/2013/12/cdc%E2%80%99s-top-ten-5-health-achievements-in-
2013-and-5-health-threats-in-2014/
8
The White House. National Strategy for Combating Antibiotic-Resistant Bacteria. Washington, DC: The
White House; 2015. Available from:
https://www.whitehouse.gov/sites/default/files/docs/carb_national_strategy.pdf
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Nurses’ Role in Hospital Antibiotic Stewardship Practices
9
Fishman, N. Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of
America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Diseases Society (PIDS).
Infect Control Hosp Epidemiol 2012; 33:322–7.
10
CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health
and Human Services, CDC; 2014. Retrieved from:
http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html
11
The Joint Commission. (2016, July). Approved: New Antimicrobial Stewardship Standard. Joint Commission
Perspective. Retrieved from:
https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf
12
Olans, RN, Olans, RD, & 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. doi:
10.1093/cid/civ697
13
Gallup. (2016). Honesty/ethics in professions. Retrieved on 12/28/16 from:
http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx
14
Olans, RD, Nicholas, P, Hanley, D, & DeMaria, A Jr. (2015). Defining a role for nursing education for staff
nurse participation in antimicrobial stewardship. Journal of Continuing Education in Nursing, 46, 318-321.
doi: 10.3928/00220124-20150619-03
15
CDC. (upd. 2016, September). Infection Prevention and Control Assessment Tool for Acute Care Hospitals
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