Nurses view patient safety as an essential component of their work and have reported a general interest in embracing an antibiotic steward role. However, antibiotic stewardship (AS) functions have not been formally integrated into nursing practice despite nurses’ daily involvement in clinical activities that impact antibiotic decisions (e.g., obtaining specimens for cultures, blood drawing for therapeutic drug monitoring). Recommendations to expand AS programs to include bedside nurses are generating support at a national level, yet a practical guidance on how nurses can be involved in AS activities is lacking. In this review, we provide a framework identifying selected practices where nurses can improve antibiotic prescribing practices through appropriate obtainment of Clostridioides difficile tests, appropriate urine culturing practices, optimal antibiotic administration, accurate and detailed documentation of penicillin allergy histories and through the prompting of antibiotic time outs. We identify reported barriers to engagement of nurses in AS and offer potential solutions that include patient safety principles and quality improvement strategies that can be used to mitigate participation barriers. This review will assist AS leaders interested in advancing the contributions of nurses into their AS programs by discussing education, communication, improvement models, and workflow integration enhancements that strengthen systems to support nurses as valued partners in AS efforts.

Executive summary: Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the “Four Moments of Antibiotic Decision Making” created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.