European Commission guidelines for the prudent use of antimicrobials in human health: a missed opportunity to embrace nursing participation in stewardship
Authors: E. Castro-Sánchez, M. Bennasar-Veny, M. Smith, S. Singleton, E. Bennett, J. Appleton, N. Hamilton, J. McEwen, R. Gallagher
Journal: Clinical Microbiology and Infection (2018)

The European Commission (EC) recently issued guidelines outlining organizational structures and human resources necessary for an effective response to antimicrobial resistance in the European Union [[1]European Commission EU Guidelines for the prudent use of antimicrobials in human health (2017/C 212/01).https://ec.europa.eu/health/amr/sites/amr/files/amr_guidelines_prudent_use_en.pdfGoogle Scholar]. These guidelines crystallize previous work by the European Centre for Disease Prevention and Control and broadly reflect contemporary recommendations. Successful antimicrobial stewardship (AS) efforts demand a sustained engagement from multiple clinical and political stakeholders, often responding to competing demands. For instance, a recent paper from Pulcini et al. [[2]Pulcini C. Morel C.M. Tacconelli E. Beovic B. de With K. Goossens H. et al.Human resources estimates and funding for antibiotic stewardship teams are urgently needed.Clin Microbiol Infect. 2017; 23: 785-787https://doi.org/10.1016/j.cmi.2017.07.013Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar] demonstrated existing gaps in resources for AS teams, and recognized that for certain models of stewardship, non-infection specialists could be not only valuable but essential. Effective implementation of AS programmes would require broad ownership and engagement beyond the boundaries of AS teams. Participation of nurses within AS efforts as described in the EC guidelines is undoubtedly positive. The document highlights, as one of the core components, the need to develop and offer education to enough specialists in infectious diseases and other professionals, which we assume would likely include nursing cadres. Additionally, the guidelines call for training on prudent antimicrobial use to be embedded in undergraduate nursing and interprofessional curricula. Those recommendations mirror closely other proposals already advocated in the United Kingdom (UK) [[3]Castro-Sánchez E. Drumright L.N. Gharbi M. Farrell S. Holmes A.H. Mapping antimicrobial stewardship in undergraduate medical, dental, pharmacy, nursing and veterinary education in the United Kingdom.PLoS One. 2016; 11 (e0150056)https://doi.org/10.1371/journal.pone.0150056Crossref PubMed Scopus (66) Google Scholar] and internationally. As nurses are the largest healthcare workforce group across Europe, it will be paramount to design, implement and evaluate AS approaches, in particular the desired knowledge, skills, attitudes and behaviours expected of nurses for optimal use of antibiotics. Perspectives about the ideal composition of AS teams have gradually evolved, from initial views that included pharmacists and infectious disease physicians exclusively, to wider approaches that embrace the versatility of nursing roles. Such flexibility is emerging worldwide, from seminal calls for the expansion of the pool of healthcare workers included in AS programmes to more recent descriptions of the practical impact of nursing stewardship. Additionally, the theoretical framework underpinning nurse stewardship is progressing so steadily that previous views about stewardship as a 'vertical' nursing intervention are transitioning to more 'horizontal' scenarios where "good stewardship is good nursing and good nursing is good stewardship" [[4]Olans R.D. Olans R.N. Witt D.J. Good nursing is good antibiotic stewardship.Am J Nurs. 2017; 117: 58-63Crossref PubMed Scopus (20) Google Scholar]. For these reasons, it is unsatisfactory that the EU document omits nursing from the core group of AS professionals in hospitals (pg. C 212/6). The lack of explicit support for nursing participation or leadership of local, regional or national public health campaigns promoting the prudent use of antimicrobials is disappointing. Equally, merely focusing on nurses as constant challengers of suboptimal prescribing or to remind other clinicians to reassess antimicrobials after 48–72 hours underutilizes the full potential of nurses in AS. Helpful statements such as "nurses should be actively involved in antimicrobial management as part of the multidisciplinary care team" are opportune; however, given the context of the guidelines it is clear that the contribution of nursing is not fully understood and requires clarification. What such active involvement actually means, in the milieu of European healthcare systems and nursing practices, warrants further debate and perhaps a consensus brokered by a supranational organization such as the European Public Health Alliance. Although the EU document seems focused on clinical practice, other recent documents depict nursing participation in AS that transcends clinical tasks. For example, the newly launched American Nurses Association/Centers for Disease Control and Prevention White Paper singled out the engagement of nursing leaders involved in clinical governance and quality as vital for the success of AS programmes. Nursing leadership for AS at an executive, strategic, and political level was the focus of a novel programme developed by the Royal College of Nursing in the UK [[5]Royal College of Nursing Antimicrobial resistance.https://www.rcn.org.uk/clinical-topics/infection-prevention-and-control/antimicrobial-resistanceGoogle Scholar]. In essence, there is growing recognition of the need for and associated benefits from defining the nursing contribution towards AS. As a result of these omissions the EU policy misses an opportunity to recognize the impact that nursing offers for AS. Quick wins could be obtained by integrating antimicrobial stewardship (AMS) tasks, roles and activities with related programmes such as infection prevention and control (IPC), hand hygiene, sepsis, or embedding AMS within patient safety and care quality, domains traditionally recognized by nurses as fundamental to their practice. Finally, complementing the proposed improvements in education and technical skills in antibiotic management with greater knowledge about the wider determinants driving antibiotic use, and consideration of the impact that nursing could have on those, would facilitate the participation of nurses in the community, in service design, executive, and advisory roles. This work was supported by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) (HPRU-2012–10047) in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London in partnership with Public Health England. ECS has received a Wellcome Trust ISSF Faculty Fellowship, an Early Career Research Fellowship from the Antimicrobial Research Collaborative at Imperial College London, and acknowledges the support of the Florence Nightingale Foundation and the NIHR Imperial Patient Safety Translational Research Centre. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the Department of Health or Public Health England. The content of this article is solely the responsibility of the authors and any conclusions or interpretations may not reflect the funders' views.