Nurses ‘under-used in antimicrobial stewardship’

June 26, 2024

Nurses should be more involved in antimicrobial stewardship, say members of an expert group working on new guidelines for antimicrobial practice.

Antimicrobial resistance (AMR) is a plague in health-care systems and infections caused by multi-resistant organisms are a serious global threat.1


Gigi Lim

Resistant micro-organisms are on the rise with AMR frequently limiting treatment options, and potentially even resulting in infections that have no suitable therapies.2 Therefore, it is important to use antimicrobials, including antibiotics, optimally to prevent both adverse drug reactions in patients and harm to the population as a whole from AMR.


Antimicrobial stewardship (AMS) is a coherent set of actions which promote the responsible use of antimicrobials to — among other things — counteract AMR. AMS programmes decrease unnecessary exposure to antimicrobials, improve cure rates, reduce adverse drug reactions, slow the emergence of AMR, and reduce hospital costs.3, 4, 5

Sharon Gardiner

Nurses are ideally placed to enhance AMS, due to the size of their workforce, their contact with patients and their wide skill-set. Yet they are under-utilised and the potential of their role in this work is not well understood.

Experts and clinical leaders recently called for our government to urgently prioritise AMS.6 They set out the need for strong interdisciplinary leadership and support for AMS activities to ensure effective action in all health-care settings.


The 2018 report, Kotahitanga – Uniting Aotearoa against infectious disease and AMR,7 from the Prime Minister’s chief science advisor, stated, “the time for action is now: the longer we wait to unite against these threats, the more suffering New Zealanders will face”.

It was recommended that New Zealand immediately “develop new clinical care standards for AMS to address gaps in the current health and disability standards”. The report said these should be extended to cover all health professionals involved with antimicrobial use, including doctors, nurses, pharmacists, midwives, and dentists in the community.

Stephen Ritchie

These roles needed to have a strong equity focus, with minimum full-time equivalents required for AMS pharmacists, doctors and nurses, as appropriate, at all hospitals (both public and private) and primary health organisations.8

New Zealanders are very high users of antibiotics. Our rate of antibiotic consumption in 2019 was the fifth highest of 31 OECD nations.9 Antibiotic use in primary care is a strong driver of AMR and, in New Zealand, over 95 per cent of antibiotics are dispensed and consumed in the community.10

It is estimated that at least half of the antibiotics prescribed in New Zealand are inappropriately used to treat self-limiting (often viral) respiratory tract infections.11

The threat of AMR in New Zealand is even greater for Māori and Pacific people, who are disproportionately affected by infectious disease (eg skin infections and sore throats, leading to risk of rheumatic fever) and have the greatest need for effective antimicrobial therapy.12

New Zealanders are very high users of antibiotics. Our rate of antibiotic consumption in 2019 was the fifth highest of 31 OECD nations.

Nurses ideally placed

Nurses comprise most of the health-care workforce13 but are significantly under-utilised in AMS.8 Registered nurses (RNs) are central to infection prevention and control teams and are ideally placed to enhance AMS activities due to their wide skillset.11

However, to succeed in this role, RNs require specific AMS education,14, 15, 16  increased participation in AMS activities, and organisational support.8, 17

Indiscriminate use of antimicrobial medicines encourages microbes to develop resistant strains. This is a major threat to the effectiveness of many medicines. Graphic: Adobe Stock

Also, further clarity is required on how RNs should carry out this role in a complex environment where engagement and collaboration with other health professionals is essential.

RNs are often the first point of contact for patients seeking advice on how to manage their illness and on treatment options (eg antibiotics). They are well-positioned to promote, teach, and support appropriate use of antibiotics and engage in AMS activities to reduce AMR.

In inpatient settings, RNs are crucial in guiding appropriate durations of antibiotic treatment, determined by individual patient response.18

Potential opportunities for RNs to engage and participate in AMS have not been fully explored. However, formal inclusion of nurses in AMS activities has been associated with improved nurse knowledge and confidence, and in some cases improved clinical outcomes for patients.19

RNs are often the first point of contact for patients seeking advice on how to manage their illness and on treatment options, such as antibiotics.

Research is needed to improve our understanding of the nature, scope, and influence of the nurse’s role in AMS, how nurses enact and carry out this role, and what support nurses need.

Therefore, we call on RNs to participate in AMS activities in both primary and secondary care settings and to engage in programmes that will enhance their practices in AMS. They need to take on the role of AMS stewards in their clinical setting and to work with doctors and pharmacists to implement programmes to slow the relentless advance of AMR.

Developing antimicrobial guidelines

There is currently an opportunity for RNs to contribute to AMS nationally, through the development of national cross-sector antimicrobial guidelines. We are members of the group of clinicians and researchers working on these guidelines which should provide a cornerstone tool of AMS and promote effective, sustainable, safe and equitable antimicrobial use.

You can find some initial information on the guideline development here. If you are interested in being informed about the progress with this or contributing to guideline development, please email: [email protected].

Infectious diseases are a major threat to the health and well-being of New Zealanders and COVID-19 serves as a stark reminder of the seriousness of these threats, physically, economically, and socially.

Infectious diseases are a major threat to the health and well-being of New Zealanders and COVID-19 serves as a stark reminder of the seriousness of these threats, physically, economically, and socially.

The science underlying the development of AMR and the solutions to AMR are evident. We need to focus our efforts on infection prevention, rather than waiting for people to get sick and then being forced to focus on treatment. We need to curb inappropriate use of antimicrobials.

The chief science advisor’s report describes the strategies needed to tackle the impending threat of AMR in New Zealand. However, as a nation, we have fallen pitifully short on implementation. The time to act is now.

Preparing and supporting RNs to participate fully in this work will greatly help us to make the changes in antimicrobial use that are needed.

Gigi Lim, RN, PhD, is a senior lecturer in the school of nursing, Faculty of Medical and Health Sciences, University of Auckland.
Sharon Gardiner, MClinPharm, PhD, is the antimicrobial stewardship (AMS) pharmacist at Health New Zealand/Te Whatu Ora – Canterbury/Waitaha, and co-lead of the New Zealand antimicrobial stewardship and infection pharmacist expert group.
Stephen Ritchie, PhD, is an infectious disease physician, and associate professor
of molecular medicine and pathology, Faculty of Medical and Health Sciences,
University of Auckland.


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