Pharmacists’ and Nurses’ Role in Antimicrobial Stewardship, Antimicrobial Resistance, and Sepsis Care
It is common knowledge when discussing sepsis treatment in hospitalized patients: the patient requires initial, rapid therapy usually involving intravenous (IV) fluids and antibiotics. But how does this approach align with antimicrobial stewardship as clinicians deal with antimicrobial resistance (AMR)? Can sepsis care work together with antimicrobial stewardship? And what role do clinicians, particularly nurses and pharmacists, have in antimicrobial stewardship and the growing problem of sepsis and AMR?
AMR occurs when bacteria, viruses, fungi, and parasites change and no longer respond to medications, making infections progressively more difficult to treat and increasing the risk of disease transmission and severe illness or death. Although AMR occurs naturally over time, the misuse and overuse of antimicrobials is a significant contributing factor that speeds up the process.
In 2020, the World Health Organization (WHO) declared AMR to be one of the top 10 global public health threats facing humanity,1 and antimicrobial stewardship and AMR was listed as one of the Top 10 Patient Safety Concerns in ECRI’s annual list in both 2019 and 2020. In the US alone, the Centers for Disease Control and Prevention (CDC) estimates that, each year, at least 2.8 million people are infected with AMR bacteria or fungi, and more than 35,000 people die as a result.2 And the situation is worsening, particularly during the coronavirus disease 2019 (COVID-19) pandemic given the steroids and broad-spectrum antibiotics that hospitalized patients continue to receive as well as the myriad of lines and tubes that enter patients’ bodies, creating a perfect storm for infection and AMR.3 Additionally, the increase and spread of AMR infections have likely been fueled by staff shortages and burnout during the pandemic, a potential decrease in screening for other infections and drug-resistant organisms, and shortages in personal protective equipment (PPE).3
The authors of Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations estimate that, annually, there will be 10 million deaths worldwide related to AMR by 2050.4 This compares to an annual 8.2 million cancer deaths, 1.5 million deaths due to diabetes, and 1.2 million traffic accident deaths. Frighteningly, data point to a possible:4
317,000 AMR-related deaths in North America
390,000 AMR-related deaths in Europe
392,000 AMR-related deaths in South America
Over 4 million AMR-related deaths each in both Asia and Africa
22,000 AMR-related deaths in Oceania (Australia and islands in the Pacific Ocean)
Not only will many lives be lost, but the economic impact will also be significant. AMR could cost the world up to $100 trillion between now and 2050.4
To help combat AMR, many hospitals and outpatient facilities have implemented antimicrobial stewardship programs to optimize antimicrobial use in ways that ensure access to effective therapy for all who need it.5 These programs typically entail measuring and improving antimicrobial prescribing and use, both to prevent delayed diagnosis or underuse of the correct antimicrobial as well as to ensure that the right drug, dose, and duration of therapy is used when antimicrobials are appropriately indicated. Antimicrobial stewardship programs can help reduce inappropriate prescriptions and broad-spectrum use of antimicrobials, improve clinical outcomes for patients and the population as a whole, slow down the emergence of AMR, and conserve healthcare resources.6
Sepsis is the body’s life-threatening response to an infection caused by either an AMR- or drug-responsive bacteria, virus, fungus, or parasite. In fact, sepsis is a common and deadly complication of COVID-19. Sepsis affects 1.7 million people and causes nearly 14,000 amputations and 270,000 deaths each year in the US. Annually, it affects more than 49 million people globally and is the largest killer of children and the primary cause of death in hospitals. The risk of mortality increases by 4-9% for every hour that sepsis treatment is delayed. As many as 80% of patients with sepsis, including septic shock (infection causing organ failure and significant hypotension), can be saved with rapid diagnosis and treatment.7
In 2020, the Sepsis Alliance conducted an online survey of adult Americans to determine their awareness of antimicrobial stewardship, AMR, and sepsis.7 The survey found that, while about three-quarters of respondents had heard of antibiotic resistance, only about half were aware of the actual meaning of the term “antimicrobial resistance.” Once respondents were educated about AMR, more than three-quarters said they were worried about it. Public understanding of antimicrobial use and AMR is important, as antimicrobial prescribing behavior is often influenced by the patients’ expectations and demands.6 The survey, which was conducted during the height of the COVID-19 pandemic, also found that only one in three adults was aware that sepsis is a complication of COVID-19. In 2021, a similar survey by the Sepsis Alliance found that only about half of the adult respondents knew that sepsis is a complication of an infection, and awareness of the signs and symptoms of sepsis and the potential aftereffects was very low.8
The Pharmacists’ Role
Pharmacists play an important role in tackling AMR and antimicrobial stewardship programs. In fact, most antimicrobial stewardship programs in hospitals and community settings are pharmacist-driven.6 Pharmacists often develop and manage facility-specific antimicrobial practice guidelines; help prescribers optimize prescribing; monitor antimicrobial use; and educate other healthcare practitioners, patients, and the public at large about antimicrobial stewardship and AMR (Table 1). They often do this by:6
Reviewing individual patient antimicrobial regimens (prescription surveillance)
Influencing the choice of antimicrobials prescribed through formulary restrictions, decision support systems, and practice guidelines
Offering guidance on dosage, preparation, and administration of antimicrobials
Reviewing and assuring proper antimicrobial duration of therapy
Pharmacokinetic monitoring and drug/dose/frequency adjustments
Monitoring the outcomes of antimicrobial usage, trends in antimicrobial prescribing, adherence to formulary/practice guidelines, and antimicrobial sensitivity patterns
Assessing antimicrobial prescriptions provided at discharge
Educating patients and the public at large about proper use of antimicrobials
Table 1. Nursing and pharmacy activities aligned with current antimicrobial stewardship models6,9
Pharmacists who are present on patient care units can also play a role in sepsis care, monitoring patients while onsite and providing feedback and guidance to optimize antimicrobial prescribing and administration. Pharmacists should also proactively promote vaccination, which can decrease the use of antimicrobials by directly preventing primary infection and indirectly preventing AMR.6
The Nurses’ Role
Nurses are the most common face of healthcare and the only practitioners who are consistently present with a hospitalized patient 24 hours a day, often playing a vital role in every aspect of patient care, from patient admission to discharge. In fact, nurses already perform practically all of the activities of antimicrobial stewardship embedded in their everyday activities (Table 1).9 However, according to a recent interview between the Sepsis Alliance and Rita Drummond Olans, an associate professor at the Massachusetts General Hospital (MGH) Institute of Health Professions, School of Nursing, current models of stewardship programs in hospitals often do not integrate bedside nurses’ contributions in the stewardship paradigm.10
When it comes to sepsis care, nurses are usually the healthcare professionals who are observing the patient 24 hours a day. They know the patient’s baseline, when the patient might be showing signs of infection, and they can quickly communicate critical information to prescribers. When necessary, nurses typically administer the antimicrobials and observe patients afterwards.
According to Olans, there are four particular moments when nurses can stand back and assess the need and use of antimicrobials for their patients by asking these questions:9,10
Day 1: Does the patient have signs/symptoms/findings that suggest that they have an infection? Were appropriate cultures obtained before the antimicrobial treatment began? Does the patient’s history support the presence of an infection?
Day 2: After 24 hours, do the culture results support the initial impression of an infection? Have the symptoms changed? Are they worse, the same, or better? As a prime communicator, has the nurse notified team members about the findings?
Days 3 and 4: Has the patient experienced any changes in their condition–worsening or improvement? Has the nurse reported the patient’s status to the team to determine if the antimicrobial treatment should continue as is, if the initial diagnosis still stands, or if treatment needs to be changed?
There is a critical need for more antimicrobial stewardship-, AMR-, and sepsis care-trained pharmacists and nurses in both hospitals and community settings. To provide this much needed education, the Sepsis Alliance has established the Sepsis Alliance Institute and the Sepsis Alliance Clinical Community to provide healthcare professionals with free quality education on these topics, several of which offer continuing education credits; to provide a safe space for discussions about antimicrobial stewardship, AMR, and sepsis care; and for exchanging information and experiences. The American Association of Critical-Care Nurses also has extensive sepsis resources. Combining educational opportunities with peer support will help pharmacists and nurses be at the forefront of antimicrobial stewardship, AMR, and sepsis care.
- World Health Organization (WHO). Antimicrobial resistance. Published October 13, 2020. Accessed September 19, 2021.
- Centers for Disease Control and Prevention (CDC). Antibiotic/antimicrobial resistance (AR/AMR). Biggest threats and data. Published March 2, 2021. Accessed September 19, 2021.
- Stone J. Untreatable, drug-resistant fungus found in Texas and Washington, DC. Medscape Nurses. July 30, 2021. Accessed September 19, 2021.
- Review on Antimicrobial Resistance (chaired by O’Neill J). Antimicrobial resistance: tackling a crisis for the health and wealth of nations. December 2014. Accessed September 19, 2021.
- Dyar OJ, Huttner B, Schouten J, Pulcini C. What is antimicrobial stewardship? Clin Microbiol Infect. 2017;23(11):793-8.
- Garau J, Bassetti M. Role of pharmacists in antimicrobial stewardship programmes. Int J Clin Pharm. 2018;40(5):948-52.
- Sepsis Alliance. 2020 Sepsis Alliance annual sepsis awareness survey. Published 2020. Accessed September 19, 2021.
- Sepsis Alliance. 2021 Sepsis Alliance annual sepsis awareness survey. Published 2021. Accessed September 19, 2021.
- Olans RD. The critical role of nurses in antimicrobial stewardship. Presentation at the Sepsis Alliance Summit 2021. September 15, 2021.
- Sepsis Alliance. Personal interview with Rita Drummond Olans, DNP, CPNP-PC, APRN, BC, FNAP, associate professor. MGH Institute of Health Professions, School of Nursing, Boston, MA. 2021.
ISMP thanks Marijke Vroomen Durning, RN, Director of Content at the Sepsis Alliance, for contributing this article. This article is being published in celebration of last week’s World Sepsis Day (September 13, 2021) and World Patient Safety Day (September 17, 2021).