The Critical Role of the Staff Nurse in Antimicrobial Stewardship--Unrecognized, but Already There.

An essential participant in antimicrobial stewardship who has been unrecognized and underutilized is the "staff nurse." Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial stewardship programs (ASPs) or defined in the medical literature, they have always performed numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy. An operational analysis of inpatient admissions evaluates these nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.

Florence Nightingale and Antimicrobial Stewardship.

Following the uniquely coincident Year of the Nurse and the year of the pandemic, striking similarities between the principles and innovations that Florence Nightingale introduced to nursing and the inclusion of nurses in the pursuit of antimicrobial stewardship have become evident. Issues of universal healthcare, the treatment of infections, workforce collaboration, and quality of care are as critical in the 21st century as they were in Nightingale's lifetime. The importance of nursing involvement in each of these areas is compared and discussed with their relevance to past, present, and future healthcare.

Effectiveness of adolescent and adult tetanus, reduced-dose diphtheria, and acellular pertussis vaccine against pertussis.

BACKGROUND: Pertussis is among the most poorly controlled bacterial vaccine-preventable diseases in the United States. In 2006, a tetanus, reduced-dose diphtheria, and acellular pertussis (Tdap) booster was recommended for adolescents and adults. Tdap vaccines were licensed on the basis of antibody response without vaccine effectiveness data. METHODS: From 30 September 2007 through 19 December 2007, a pertussis outbreak occurred at a nursery through twelfth grade school on St. Croix, US Virgin Islands. We screened all students for cough and collected clinical history, including Tdap receipt. Coughing students were offered diagnostic testing. We defined clinical case patients as students with cough 14 days in duration plus either whoop, paroxysms, or post-tussive vomiting, and we defined confirmed case patients as students with any cough with isolation of Bordetella pertussis or those with clinical cases and polymerase chain reaction or serological evidence of pertussis; other clinical cases were classified as probable. RESULTS: There were 51 confirmed or probable cases among 499 students (attack rate, 10%). Disease clustered in grades 6-12, with a peak attack rate of 38% among 10th graders. Of 266 students aged 11 years with complete data, 31 (12%) had received Tdap. Forty-one unvaccinated students (18%) had confirmed or probable pertussis, compared with 2 (6%) of the vaccinated students (relative risk, 2.9); vaccine effectiveness was 65.6% (95% confidence interval, -35.8% to 91.3%; P = .092). CONCLUSIONS: This first evaluation of Tdap vaccine effectiveness in the outbreak setting suggests that Tdap provides protection against pertussis. Increased coverage is needed to realize the full benefit of the vaccine program. Serological testing was an important tool for case identification and should be considered for inclusion in the Council of State and Territorial Epidemiologists case definition.

Nurses and Antimicrobial Stewardship: Past, Present, and Future.

Successful antimicrobial stewardship programs must be a truly collaborative multidisciplinary team effort. Nurses have critical contributions and are recognized more in publications about antimicrobial stewardship. Examination of patient care workflow patterns indicates the central role of nurses in the application of stewardship concepts in patient care. Education about antimicrobial resistance and antimicrobial stewardship is important not only for nurses and other health care providers but also for the general public. Analysis of the health care workforce population shows the importance of integrating this largest segment of health care providers in the routine daily care of patients into all stewardship efforts.

A Multidisciplinary Approach to Incorporate Bedside Nurses into Antimicrobial Stewardship and Infection Prevention.

BACKGROUND: Antimicrobial stewardship programs exist to promote appropriate antimicrobial use. The Joint Commission has reported that although many US hospitals have implemented basic components of antimicrobial stewardship programs, there now exists a need for innovative, multidisciplinary approaches, including involving frontline clinicians such as bedside nurses. METHODS: A retrospective evaluation of bedside nurse-driven antimicrobial stewardship and infection prevention rounds was conducted on a 31-bed telemetry unit of a community regional medical center. Rounds were managed by a nurse coordinator and attended by an infectious diseases pharmacist, an infection preventionist, and a nurse practitioner. Primary outcome measures were antimicrobial and acid suppressant medication and invasive catheter use. RESULTS: In the 12-month intervention period the nurse-driven rounds team reviewed of a total of 472 antimicrobial medication, 480 acid suppressant medication, 321 urinary catheter, and 61 central venous catheter therapies over 867 total patient encounters. Compared with the 12-month preintervention period, significant reductions in unit antimicrobial use (791.2 vs. 697.1 days of therapy per 1,000 patient-days; p = 0.03), acid suppressant medication use (708.1 vs. 372.4 days of therapy per 1,000 patient-days; p = 0.0001), and urinary catheter use (0.3 vs. 0.2 catheter-days per patient-day; p = 0.002) were observed. CONCLUSION: This study demonstrates successful engagement of bedside nurses in antimicrobial stewardship and infection prevention activities and a measurable impact on meaningful outcomes. More studies of strategies to integrate bedside nurses in antimicrobial stewardship are needed.

Good Nursing Is Good Antibiotic Stewardship.

: Resistance to antibiotics has increased dramatically in the United States, with serious associated medical, social, and economic consequences. The most promising approach to this national crisis is a new understanding of the need for the careful and responsible use of antibiotics, both for the benefit of society and for the optimal care of each patient. This multidisciplinary approach, called antimicrobial stewardship, has typically involved specialists but not necessarily nurses, who perform numerous antibiotic-related activities daily and should be an integral part of antimicrobial stewardship programs. In this article, we use patient examples to review several stewardship activities and illustrate how nurses are essential to the appropriate use of antibiotics.

Serial nosocomial transmission of Plasmodium falciparum malaria from patient to nurse to patient.

BACKGROUND: Nosocomial transmission of malaria is a rare phenomenon in the United States. OBJECTIVE: To describe the probable transmission of Plasmodium falciparum malaria from a patient to a healthcare worker and then from the healthcare worker to another patient. DESIGN: Case series. SETTING: Two community hospitals in Massachusetts. INTERVENTION: Routine medical and supportive care. MEASUREMENTS: Clinical and laboratory evaluation. RESULTS: A nurse developed falciparum malaria after a needlestick injury from a patient with documented falciparum malaria. Three days prior to her diagnosis, she cared for another patient, who subsequently developed falciparum malaria. That patient's parasite isolate genetically matched the nurse's isolate by two independent DNA fingerprinting techniques. CONCLUSION: After extensive evaluation, we believe that a nurse who had acquired falciparum malaria via needlestick subsequently transmitted malaria to another patient via a break in standard precautions. The implications of this mechanism of transmission are discussed.