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Original Research

Nurses’ Role and Understanding of the Application of Antimicrobial Stewardship Principles in Hematology Settings

Sangojoyo, Jennie BN(Hons),; Hutchinson, Ana BN, PhD,; Cohen, Emma PhD; Bouchoucha, Stéphane L. PhD, RN

Author Information
doi: 10.1097/CR9.0000000000000013
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The importance of antimicrobial stewardship (AMS) in acute care settings is well established; however, challenges remain in achieving consistent implementation of AMS principles at the bedside. Nurses have been identified as an under-used resource to support and promote AMS implementation in clinical practice settings, and there is current interest in identifying the most effective ways to engage nurses to take an active leadership role in AMS initiatives.1 Nurses working in specialty areas such as critical care, emergency departments,2 and specialist hematology and oncology wards have been identified as having the potential to take a more active role in AMS activities within their specialty practice area.3 In the current study, we explored hematology nurses’ role and understanding of the implementation of AMS within an acute specialty hematology service.

There are a few key principles of AMS,1 the first one being timely assessment of the need for antibiotic therapy. This is to ensure both prompt initiation of antimicrobial therapy for high-risk patients and those with signs of severe infection and avoiding antibiotic use when not clinically indicated. Second, guiding clinicians in choosing the right antibiotic regimens. The third principle is appropriate administration of antibiotics, including dose, frequency, and early reassessment of response to treatment to determine whether the therapy should be continued, changed, or discontinued. Last, the importance of continuous and transparent monitoring of antimicrobial usage that can be used for: audit and feedback to prescribers regarding antimicrobial usage patterns, staff education and to assess the efficacy of antimicrobial therapies.

As antibiotics are widely used in the hematological setting, and their use is often time critical, it is essential that there are policies and procedures empowering nurses to implement antibiotic treatment for specific patients and/or conditions. Timely management of neutropenic sepsis with antibiotics is pivotal as delays can result in a higher risk of complications such as the development of septic shock, end-organ failure, and increased mortality rates.4 Furthermore, strategies to ensure optimal antimicrobial use are critical in the context of the emergence of multidrug-resistant microorganisms.5,6 This is especially important as some treatments pose a higher risk to patients with hematological disorders, for example, patients receiving allogeneic hematopoietic stem cell transplantation and patients with leukemia are at a higher risk of developing infections than those receiving chemotherapy for solid tumors.7,8 This is due to the degree and duration of immunosuppression5,9 and although the proportion of deaths caused by infection after receiving treatments for hematological malignancies has reduced, it remains a global challenge. This excess mortality is predominantly due to the need to treat complex infections associated with antimicrobial resistant microorganisms.10

Febrile neutropenia can be a life-threatening complication of chemotherapy and is one of the emergencies needing immediate attention and treatment for patients with hematological disorders,8,11–14 as these patients are at a higher risk of developing life-threatening medical complications and death.15 When an infection is proven or highly suspected, empirical antibacterial therapy with broad-spectrum antibiotics is the evidence-based, first-line treatment.16,17 Early recognition and response to sepsis is also highlighted by policy makers and clinicians alike as a key component of AMS initiatives aimed at improving outcomes for patients with life-threatening conditions.18,19 To ensure timely administration of antimicrobials, severe infections need to be recognized early and treatment commenced expeditiously, with recommendations that antibiotics need to be administered within 30–60 minutes of presentation with febrile neutropenia.11,20–22

Nurses have an active role in the management of febrile neutropenia, including early identification of sepsis and implementation of AMS principles such as obtaining microbiological samples for septic screen before antibiotic administration and administering antibiotics in a timely manner.23 Strategies such as sepsis pathways or care bundles have been successfully implemented in emergency departments and inpatient settings to promote early recognition and response to suspected sepsis with the goal of reducing sepsis-related morbidity. Sepsis bundles typically include treatment algorithms to guide provision of evidence-based sepsis management and identify key responsibilities where nurses can take the lead in initiating diagnostic work-up and treatment.24,25

While a multidisciplinary approach is recommended for successful AMS program,26 nurses are often under-represented or underutilized in the development and implementation of AMS guidelines.27,28 The addition of nurses as part of the AMS team is supported by a number of peak organizations including the Centers for Disease Control and Prevention in the United States, the American Nurses Association, and the American Academy of Nursing.29,30 While in Australia, very few registered nurses can prescribe, all registered nurses engage in numerous activities that involve operationalizing AMS principles including: obtaining pathology samples, safe preparation and administration of antimicrobial agents,1,31 monitoring and reporting patients’ response to treatment, and the occurrence of side effects and/or adverse events associated with antimicrobials therapy. These activities all influence the success of AMS initiatives.32

Among current strategies to increase nurses’ role in AMS implementation, the hematology ward at the study site introduced a nurse-led sepsis bundle called “NIFTY” (Nurse Initiated Febrile neutropenia TherapY) pathway,33 to aid nurses managing febrile neutropenia, including recognizing signs and symptoms of sepsis, and empowering them to take more of an active role in the timely administration of patients’ antimicrobial therapy. This pathway was introduced in 2018 and to support the pathway implementation, evidence-based, clinical guidelines that provided detailed recommendations to direct the care of patients with neutropenic fever and/or suspected sepsis were also made available to staff.34 While this pathway enabled nurses to take a proactive role in the management of neutropenic sepsis, the links between the NIFTY pathway and AMS might not be evident to some clinicians.

Although nurses play a key role in the implementation of clinical practice guidelines for appropriate antibiotic usage, there has been limited research exploring nurses’ knowledge of AMS and how these principles are applied in the hematology setting. The study aim was to explore hematology nurses’ understanding of the application of AMS principles in hematology settings and their experience of using a nurse-initiated neutropenic sepsis pathway.


An exploratory descriptive qualitative research design (EDQ) with focus groups was use. An EDQ approach was the preferred approach, as the experiences of participants are explored and described in relation to the phenomena under study; furthermore, the thematic analysis identified the main statements and the core of the participants’ experience and as such generalization is possible.35


The study was conducted on a specialized hematology ward at a tertiary referral center. The study ward is a 32-bed ward that specializes in providing inpatient care for patients diagnosed with hematology malignancies. The study ward has a local protocol called the “NIFTY” pathway as part of treatment for patients who are neutropenic. This pathway outlines key criteria for recognition of neutropenic sepsis and includes preprescribed antibiotics, to enable timely administration when a patient meets these “activation” criteria. Other AMS initiatives on the study ward include: antibiotic allergy assessment tool that functions to identify patients with antibiotic allergy, especially penicillins, and assess whether they are eligible to have antibiotic rechallenge: as well as the stopping antibiotic in selected stable inpatients, which is a protocol to cease antibiotic prescription based on certain clinical parameters. All these initiatives have been the outcome of multidisciplinary input and collaboration between the hematology and infectious diseases teams.


A convenience sampling approach was taken to recruit participants. An email invitation to nurses working on the study ward was sent by a staff member independent from the study team (ward clerk) to potential participants’ organizational email addresses. The email contained details about the research project including its nature and aims, dates and time of focus groups sessions, and the study contact person. In addition, this research study was publicized in the weekly ward newsletter sent to all staff members and was also promoted on the ward after nurses’ group handover. A total of 3 focus groups were conducted. It was anticipated that an approximate sample of 16–20 participants would provide sufficient information power for descriptions of different experiences and contribute new knowledge.36 Participation in the study was voluntary and participants were informed that there would be no direct benefits in participating in the study to them.

Data Collection

Eighteen nurses participated in the study, as theoretical data saturation37 was achieved after the 3 focus groups. Focus groups sessions were held in the middle of the day, when double staffing enabled the maximum recruitment of participants. Open-ended questions were used as prompts to facilitate discussion and follow-up questions were used to enable participants to provide in-depth answers. Each focus group was of approximately 20–30 minutes duration. All participants provided written informed consent prior to the commencement. To ensure anonymity of participants, minimal demographic data were collected, and participants were deidentified using an anonymous study number. No identifiable data were collected from participants. Data collected on paper forms were stored in locked filling cabinets and any electronic data stored in password protected files on a secure server. Only research team members had access to the data.

Ethics Approval

Ethics approval was obtained from the health service (reference: HREC/52329/xxx-2019) and the supporting academic institution (reference: 2019-271) before the start of the data collection.

Data Analysis

Participants’ responses were audio recorded and transcribed verbatim. A thematic analysis of the qualitative responses was undertaken using the Braun and Clarke framework.38 A thematic analysis is suited to an EDQ design as highlighted by Green and Thorogood.39 The interviews transcripts were examined independently line by line by 2 researchers (A.H. and J.S.), to identify common themes, patterns, and categories that emerged. The 2 researchers then compared the initial categories identified in the interview transcripts and grouped these categories. Common themes and subthemes were then identified by consensus. To increase the rigor, the thematic structure and supporting quotes were reviewed by the other members of the research team (E.C. and S.L.B.), this allowed for discussion of alternative interpretations and assisted in identifying any personal biases or preferences on how the analysis was approached.40,41 The research team included hematology clinicians and infection prevention and control experts. The data analysis approach increased rigor as it enabled discussion taking into account relevant expretise needed for such study.


Of the 18 participants, 16 were females and 2 were males. Participants’ mean age was 32.2 (SD = 9.7), and their mean years of clinical experience was 4.8 (SD = 6).

Thematic analysis derived 3 major themes: (1) nurses taking the lead in sepsis management; (2) timely management of neutropenic sepsis; and (3) nurses’ knowledge of AMS principles. The subthemes associated with each major theme are summarized in Table 1.

Table 1. - Major Themes and Subthemes
Major Themes Subthemes
Nurses taking the lead in sepsis management Empowerment through implementation
Taking the lead in clinical care
Integrating AMS principles into Timely management of neutropenic sepsis Supporting AMS processes
Assessing treatment response and ongoing need for antimicrobials
Nurses’ knowledge of the principles of AMS Familiarity with commonly used antibiotics
Availability of education and clinical decision support
Abbreviation: AMS, antimicrobial stewardship

Theme 1: Nurses Taking the Lead in Sepsis Management

The first major theme that emerged from the focus groups was nurses leading role in early recognition and initiation of treatment for septic neutropenic patients. Participants highlighted that they had an excellent understanding of the NIFTY pathway and that the introduction of this policy a few years earlier had empowered them to take a leading role in sepsis management. This was demonstrated not only by their leadership in early identification of patients with neutropenic sepsis but their ability to commence antibiotics within the evidence-based timeframe of 30–60 minutes.

Subtheme 1.1: Empowerment Through Implementation of a Nurse-initiated Treatment Pathway

Participants’ responses showed that nurses perceived the introduction of the NIFTY protocol had empowered them to play a key clinical leadership role in ensuring timely assessment and antibiotic administration for patients who reach key clinical criteria putting them at high risk of neutropenic sepsis. One participant explained:

Because we have NIFTY, starting antibiotics for examples in patients that are neutropenic, so if they are immunocompromised then [we can activate the NIFTY protocol]. If we have someone who has finished chemotherapy six months ago, and has a solid organ tumor, and they have a temperature of 37.5; we wouldn’t really care [as they are not eligible for the pathway], we wouldn’t be starting antibiotics on them straightaway (N18).

Participants identified that as they were responsible for ongoing patient monitoring, and that they had a key role in early recognition of febrile neutropenia and ensuring timely antibiotic administration. For example:

Yes, [we are] the first people to check the obs [vital signs observation], so you’re the first to see the temperature and it’s your responsibility to follow up and escalate […] do all the blood cultures, antibiotics, quickly. So, it’s really your responsibility to do all that. It’s mainly falls back on us (N7).

When asked about what signs and/or symptoms of infection might trigger the implementation of the protocol, participants mentioned: “Runny nose, coughing, shivering” (N1), “gastro symptoms, vomiting, diarrhea, rashes” (N6), “Neutropenic and febrile” (N3); and “If I think it’s [a temperature of] about 37.5” (N6). Some participants expanded this commenting:

Temperature, they have abnormal temperature. Visually, I hate to say it, when someone looks, you know, not right. (N8)


So neutropenic, lung infections, fungal infections, PJP [Pneumocystis Jiroveci Pneumonia or PCP (Pneumocystis Carinii Pneumonia)] with the ongoing immunocompromised, plus ongoing steroids and things that [put the patients] at risk. (N14)

Subtheme 1.2: Nurses Taking the Lead in Clinical Care

One recognized benefit of the nurse-initiated NIFTY pathway was a reduction in the time to antibiotic administration, with one participant stating: “We start early because we’ve identified that they are febrile and usually [administer antibiotics] within half an hour. And then the registrar gets informed again, that “we activated NIFTY.” Our average time now, is about 20 minutes” (N18). Participants described being empowered by the introduction of a protocol that allowed nurses to act as soon as signs of infection were identified, commenting: “it gives … I guess not authority, but you can act on what you know you need to do” (N6). They also perceived their main role as leading in treatment of sepsis:

“We … ensure that antibiotics are administered within that half hour and continue the monitoring post [administration]. So, I think this is the main role, like we have been given direction … having that nurse-initiated protocol available.” (N2)


Before NIFTY, if someone had a temperature overnight, because that is when patients usually spike [their temperature], you notify the doctor, you page the doctor, we put it on task manager, and you wait” (N18).

Another benefit participants highlighted was an increased sense of teamwork with nurses helping one another to perform tasks prescribed in the protocol: “generally, if you tell someone one of your patients has a temperature, people get stuff ready for you, so it can be done faster” (N7) and “there always someone to help” (N8). Participants also recognized that timely administration of antibiotics had the potential to improve patient outcomes, commenting:

I guess it’s an 80% increase in mortality if you don’t give antibiotics within half an hour after having high temperature. … So, if it can be done fast, that works with everyone. (N7).

These findings demonstrate that the introduction of a nurse-led sepsis management pathway (NIFTY) provided nurses with the confidence and authority to take the lead in initiating timely early management of neutropenic sepsis on their ward.

Theme 2: Integrating AMS Principles into the Timely Management of Neutropenic Sepsis

The second major theme was that participants understood the importance of the NIFTY pathway to facilitate timely management of sepsis in neutropenic patients. It was recognized that some key AMS principles were integrated in this pathway.

Subtheme 2.1: Supporting AMS Processes

Participants identified their responsibility for supporting processes of care for septic neutropenic patients by being aware of the patients’ illness trajectory and making sure that the NIFTY pathway was prescribed for patients who met the criteria.

I guess it is sort of our responsibility to make sure that they have the NIFTY there, doctors don’t actually chart it all the time, so we actually make sure that it’s there ready… if we do need it (N7)


Just make sure that they [patients] fit the criteria, they have to have a neutrophils count dropping or, no neutrophils at all. If they’re trending up, then they might not qualify for it [NIFTY]. So just knowing where the patient is and their trajectory of disease and treatments, making sure that they get the appropriate antibiotic charted. (N17)

Another aspect of AMS is ensuring that antibiotic prescribing protocols are followed before administering antibiotics. Participants stated that they needed to make sure that the Infectious Diseases (ID) approval number was valid prior to administering antibiotics dose. For example: “so, like checking the number [ID approval number] and just making sure that it is still appropriate” (N8).

Most participants displayed an understanding of the key steps of the NIFTY pathway including taking a full blood work-up (blood cultures and sometimes venous blood gas [VBG]) before administrating the pre-prescribed antibiotics. The importance of obtaining blood cultures prior to antibiotic administration so that potential pathogens were more likely to be identified by pathology was also recognized by the study participants. For example: “blood cultures from the central line and blood cultures peripherally, before you start the antibiotics, and it’s quick antibiotics within the half hour or hour” (N1),

While the benefits of NIFTY were clearly identified, there were a few aspects of implementation that participants stated needed improvement (N6, 14, 18). Although antibiotics were preprescribed, nurses still needed to ask doctors to order blood cultures and VBGs. “So, we have a pre-existing order for the antibiotics, but we don’t have a pre-existing order for blood cultures, because we don’t have a computer system that allows us to do that.” (N18).

In addition, some participants found it hard to work with new junior doctors not familiar with the NIFTY protocol as they relied on nurses to explain the process.

It’s hard having a covering doctor who isn’t, a Hematology [team member] …and trying to explain to them what you need and why you need it. At least having a documented protocol, it backs you up. (N6).

Subtheme 2.2: Assessing Treatment Response and Need for Antibiotic Treatment

Participants identified that they had an ongoing role in monitoring patients’ response to treatment, for example: “They would just do standard daily blood cultures to monitor whether they’re not really febrile or not.” (N6) and “We usually have a daily blood cultures until it’s negative or they pull the Hickman’s or PICCs [Peripherally Inserted Central Catheter lines] out if they’re infected” (N7).

In addition, all patients had their antimicrobial therapy reviewed and adjusted based on their culture results, for example: “If it comes back positive but is resistant against whatever the NIFTY [antibiotic prescribed], let’s change it appropriately” (N14) and “If patients are increasing their body temperatures [fever], we have to get different antibiotics charted, and get them reviewed…” (N7). Although nurse participants indicated that they were aware of the importance of checking culture results, a number commented that this process did not fit into their current workflow. For example:

Sometimes, it’s a time thing. If you don’t have time to sit down and look at your patients results, then we hope the doctors look through on the ward round. But if I have time, I see if there are any positives and make sure they’re on the right antibiotics. (N6).

Others however, always checked pathology results and found it easy to determine abnormalities: “I do, I always check to see if it’s been positive, negative” (N14); “it’s easy to check they come up red [on the computer results]” (N18).

These findings demonstrate that the steps contained within the NIFTY pathway made aspects of nurses’ role in AMS explicit, promoting participation in key aspects of AMS such as obtaining cultures prior to antibiotic administration and review of pathology results to evaluate antimicrobial sensitivities.

Theme 3: Nurses’ Knowledge of the Principles of AMS

The focus group findings highlighted that although nurses had a clear understanding of their role in sepsis management, they had limited knowledge of other aspects of AMS.

Subtheme 3.1: Familiarity with Commonly Used Antibiotics

The nurse participants demonstrated that they were familiar with the types of antibiotics recommended for first line therapy for neutropenic sepsis, commenting:

…because our patients are usually always on antibiotics, prophylactic BactrimTM [sulfamethoxazole and trimethoprim] or they get infections at home intermittently, and so they get a course of oral antibiotics, whereas surgical patients … are maybe on different treatment (N18).

With regard to new staff members, some participants expressed that there was a need for more education to instill confidence in the whole team about the use of the NIFTY protocol. For example: “It [the NIFTY protocol] is in its infancy in this organization, too. So, it’s just making people aware, many new staff need reinforcement” (N2); “Confidence, as there’re not too many nurse-initiated protocols” (P2) and “Not understanding either, … how important it is … and why we have it in place” (P6).

Subtheme 3.2: Availability of Education and Clinical Decision Support

The nurse participants identified a range of external resources such as the nurse unit managers, ID department and pharmacists that could be accessed when they required expert advice, stating:

The ID team will come over and review and make sure that they’re on the right antibiotics and not for too long. I think the nurses do well communicating with them (N2)


“Pharmacists have a big input, they are often a great resource, and the doctors with both their hematology team and they are often in charge, ID team are involved with them, [discussing] what their plans are” (N17).


The study findings demonstrate that the introduction of the NIFTY pathway provided nurses with the authority to implement key aspects of AMS. These included being able to initiate obtaining cultures and administering guideline-based empiric antibiotic therapy. Participants reported that this had resulted in measurable improvements in time to first dose antibiotics in patients with neutropenic sepsis on the ward. Although the study participants understood the key elements of the NIFTY pathway and their role in ensuring early and timely management of neutropenic sepsis, the study findings highlight that they had limited understanding of AMS principles in general.

Furthermore, the findings highlight that the NIFTY pathway has increased nurses’ role in the implementation of AMS and early sepsis management in this hematology unit. Implementation of the pathway assisted nurses in early identification and response to signs and symptoms of infection in immunocompromised patients. Moreover, it had empowered nurses to not only recognize, but also to take action to avoid neutropenic sepsis when they identified early signs of sepsis such as fever in their patients.42 As the reported incidence of febrile neutropenia is between 70% and 100%,43 early initiation of treatment by nurses has the potential to improve outcomes for a high proportion of hematology patients.

Nurses have a unique role in the early identification of patients with sepsis, being at the frontline and due to their frequent interactions and assessments of patients.44 Previous studies have shown that nurse-led protocols are safe and effective systems to manage febrile neutropenia. For example, >90% patients in a study that was conducted in a hospital in England received their first dose of antibiotic within an hour of presentation.45 Other researchers also found improvements in the proportion of patients who had blood culture and serum lactate testing and overall time to administration of antibiotics, which are all elements of best practice in sepsis management.46,47

The NIFTY protocol enabled nurses to activate treatment, meaning they were able to administer the preprescribed antibiotics to patients who met the protocol criteria without waiting for doctors’ orders and the results of investigations.48 Participants from the study ward had a good understanding of the NIFTY protocol, which was developed to incorporate and promote implementation of the principles of AMS in clinical practice. For example, one aspect of this nurse-initiated procedure is to take pathology, before administering the antibiotics prescribed. This is part of the second statement in the AMS Clinical Care Standard the requirement for microbiological testing before commencing treatment that functions to support clinicians to individualize prescribing and select the most appropriate antibiotic treatment.18 While anti-infective drugs are the most prescribed drugs by nurse practitioners (NPs) in Australia,49 not all hematological inpatient areas have access to NPs. Having a protocol such as NIFTY enabled nurses with no prescribing rights to take an active role, in often time critical situation to support patients and improve their outcomes and sepsis outcomes. Other countries may have different prescribing regulations for nurses and as such findings might be limited to Australian settings.

The findings from the current study show, however, that there were also clear gaps in nurses’ AMS knowledge. This is similar to findings from Kilpatrick et al50 study showing that most nurses who participated were not aware of the term AMS. In addition, the majority of participants raised concerns about the need for more education on AMS policies that have been implemented in the hospital, which supports Kilpatrick’s findings.

Although participants understand their role in the application of AMS’ principles for early identification, early taking blood cultures, and early antibiotic administration, they perceived that they had a limited role in early review of pathology results. They also did not fully elaborate their role with regard to patient education about antimicrobial treatments. This is an essential part of the nursing role and is also emphasized as a key aspect of consumer participation in care, now part of the national standards for antimicrobial administration.18 In addition, when asked about AMS, other-related AMS initiatives that have been implemented on the study ward (such as “de-labeling” of patients with a history of beta-lactam allergy) were not identified by participants.51 This finding indicates that participants had a limited understanding of AMS activities overall.

Strengths and Limitations

This study is one of the first that not only investigated nurses’ knowledge of a nurse-initiated protocol on administering early antibiotic for febrile neutropenia patients, but also the perceptions of their clinical role in AMS when looking after hematology patients. This study further explored nurses’ understandings of AMS principles, including the key steps after identifying sepsis symptoms, performing a septic screen, and administering antibiotics, such as reviewing pathology results (blood cultures and other tests) and patients’ response to antibiotic therapy.

The focus group discussions included participants with a mixed level of experience, which had the potential disadvantage that less experienced participants were less likely to express their views. The thematic analysis, however, provided evidence that most participants contributed to the discussions. Further given the study was conducted in a tertiary hospital, doctor rotation, and nurse turnover are the clinical reality. The nurses in the current study did indicate that further education would be useful in ensuring that those working on the unit, even briefly, understood the protocol.

Thematic analysis using 2 independent researchers to examine the qualitative data was used in this study. This was done to reduce any potential risk of bias in the data analysis and interpretation. To increase the credibility, another 2 independent researchers then evaluated themes that emerged from the data in conjunction with their supporting quotes to identify alternative interpretations and any personal biases that might be raised from the first analysis.

Although participants were recruited from 1 ward in 1 metropolitan tertiary referral center, AMS principles apply to many settings and countries across the globe. As such, findings from this study are important to consider when developing interventions to facilitate nurses’ role in AMS and/or clinical pathways empowering nurses to implement early recognition and treatment of neutropenic sepsis for hematology patients.


The role of nurses in AMS in acute care settings is an emerging theme in the research literature and more recently nurses’ role has been more formerly recognized in health service standards and policies in Australia. Despite this, in clinical practice settings, many nurses may be unclear how they should take a more active role in AMS when they are not directly involved in antimicrobial prescribing. The findings in this study demonstrate that the introduction of a clinical pathway embedding AMS principles that provided explicit, actionable roles, and responsibilities for nurses enabled nurse participation in AMS and gave them the authority to play an active leadership role within the multidisciplinary team. The finding that nurses had low levels of knowledge and awareness of other AMS activities within the oncology unit also highlights the need to link AMS education and awareness raising to identifiable nursing responsibilities and to integrate these within their workflow. Whether this finding is because hematology nurses are highly specialized would need to be investigated in future studies. It is also essential to articulate that AMS is an integral part of early sepsis management to ensure nurses’ knowledge of AMS increases and clear links between sepsis management and AMS are made. The success of the NIFTY pathway in ensuring early management of neutropenic sepsis provides an exemplar for future projects developing hematology nurses’ leadership role in AMS.

Relevance to Clinical Practice

This study is one of the first studies to describe nurses taking an active role in AMS processes of care. Through a nurse-initiated sepsis care pathway, nurses can overcome the barriers to early treatment of neutropenic sepsis and improve patient outcomes in this time critical pathology. Furthermore, to improve timely treatment, these pathways need to be available and include prewritten orders allowing nurses to administer care based on agreed clinical indicators. Findings from this study clearly demonstrate that the use of sepsis management pathways give nurses the opportunity to develop their leadership in clinical practice.


We would like to acknowledge the contribution and leadership provided by Dr Emma Cohen, Nurse Unit Manager of the Haematology Ward at Austin Health. Dr Cohen passed away in 2020; however, her passion and leadership has made a lasting impact on oncology nursing.


1. Gotterson F, Buising K, Manias E. Nurse role and contribution to antimicrobial stewardship: An integrative review. Int J Nurs Stud. 2021;117:103787.
2. van Huizen P, Kuhn L, Russo PL, et al. The nurses’ role in antimicrobial stewardship: a scoping review. Int J Nurs Stud. 2021;113:103772.
3. Rout J, Brysiewicz P. Exploring the role of the ICU nurse in the antimicrobial stewardship team at a private hospital in KwaZulu-Natal, South Africa. South Afr J Crit Care. 2017;33:46–50.
4. Braga CC, Taplitz RA, Flowers CR. Clinical implications of febrile neutropenia guidelines in the cancer patient population. J Oncol Pract. 2019;15:25–26.
5. Ruhnke M, Arnold R, Gastmeier P. Infection control issues in patients with haematological malignancies in the era of multidrug-resistant bacteria. Lancet Oncol. 2014;15:e606–e619.
6. Lingaratnam S, Slavin M, Mileshkin L, et al. An Australian survey of clinical practices in management of neutropenic fever in adult cancer patients 2009. Intern Med J. 2011;41:110–120.
7. Mackall C, Fry T, Gress R, et al.; Center for International Blood and Marrow Transplant Research (CIBMTR); National Marrow Donor Program (NMDP); European Blood and Marrow Transplant Group (EBMT); American Society of Blood and Marrow Transplantation (ASBMT); Canadian Blood and Marrow Transplant Group (CBMTG); Infectious Disease Society of America (IDSA); Society for Healthcare Epidemiology of America (SHEA); Association of Medical Microbiology and Infectious Diseases Canada (AMMI); Centers for Disease Control and Prevention (CDC). Background to hematopoietic cell transplantation, including post transplant immune recovery. Bone Marrow Transplant. 2009;44:457–462.
8. Lingaratnam S, Worth LJ, Slavin MA, et al. A cost analysis of febrile neutropenia management in Australia: ambulatory v. in-hospital treatment. Aust Health Rev. 2011;35:491–500.
9. Babady NE. Laboratory diagnosis of infections in cancer patients: challenges and opportunities. J Clin Microbiol. 2016;54:2635–2646.
10. Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global multifaceted phenomenon. Pathog Glob Health. 2015;109:309–318.
11. Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52:e56–e93.
12. Klastersky J, de Naurois J, Rolston K, et al.; ESMO Guidelines Committee. Management of febrile neutropaenia: ESMO clinical practice guidelines. Ann Oncol. 2016;27(suppl 5):v111–v118.
13. Lucas AJ, Olin JL, Coleman MD. Management and preventive measures for febrile neutropenia. P T. 2018;43:228–232.
14. Ogawara D, Fukuda M, Ueno S, et al. Drug fever after cancer chemotherapy is most commonly observed on posttreatment days 3 and 4. Support Care Cancer. 2016;24:615–619.
15. Lyman GH. Febrile neutropenia: an ounce of prevention or a pound of cure. J Oncol Pract. 2019;15:27–29.
16. Averbuch D, Orasch C, Cordonnier C, et al. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the 2011 4th European Conference on Infections in Leukemia. Haematologica. 2013;98:1826–1835.
17. Tam CS, O’Reilly M, Andresen D, et al.; Australian Consensus Guidelines 2011 Steering Committee. Use of empiric antimicrobial therapy in neutropenic fever. Australian Consensus Guidelines 2011 Steering Committee. Intern Med J. 2011;41(1b):90–101.
18. Australian Commission on Safety and Quality in Health Care (ACSQHC). Antimicrobial Stewardship in Australian Health Care. 2018. Accessed May 15, 2020.
19. MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev. 2005;18:638–656.
20. Keng MK, Thallner EA, Elson P, et al. Reducing time to antibiotic administration for febrile neutropenia in the emergency department. J Oncol Pract. 2015;11:450–455.
21. Legrand M, Max A, Peigne V, et al. Survival in neutropenic patients with severe sepsis or septic shock. Crit Care Med. 2012;40:43–49.
22. Perron T, Emara M, Ahmed S. Time to antibiotics and outcomes in cancer patients with febrile neutropenia. BMC Health Serv Res. 2014;14:162.
23. Forde C, Scullin P. Chasing the golden hour–lessons learned from improving initial neutropenic sepsis management. BMJ Open Qual. 2017;6:u204420.
24. Dellinger RP. Foreword. The future of sepsis performance improvement. Crit Care Med. 2015;43:1787–1789.
25. Torsvik M, Gustad LT, Mehl A, et al. Early identification of sepsis in hospital inpatients by ward nurses increases 30-day survival. Crit Care. 2016;20:244.
26. Centers for Disease Control and Prevention (CDC). Impact of antimicrobial stewardship program interventions on antimicrobial resistance. 2015. Accessed May 15, 2020.
27. Fisher CC, Cox VC, Gorman SK, et al. A theory-informed assessment of the barriers and facilitators to nurse-driven antimicrobial stewardship. Am J Infect Control. 2018;46:1365–1369.
28. Mostaghim M, Snelling T, McMullan B, et al. Nurses are underutilised in antimicrobial stewardship – results of a multisite survey in paediatric and adult hospitals. Infect Dis Health. 2017;22:57–64.
29. American Nurses Association. redefining the antibiotic stewardship team: recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the role of registered nurses in hospital antibiotic stewardship practices. 2018. Accessed January 12, 2020.
30. Padigos J, Ritchie S, Lim G. Nurses have a major role in antimicrobial stewardship. N Z Nurs J Kai Tiaki. 2017;23:16–45.
31. Castro-Sánchez E, Gilchrist M, Ahmad R, Courtenay M, Bosanquet J, Holmes AH. Nurse roles in antimicrobial stewardship: lessons from public sectors models of acute care service delivery in the United Kingdom. Antimicrob Resist Infect Control. 2019;8:1–8.
32. Kilpatrick M, Hutchinson A, Manias E, et al. Paediatric nurses’, children’s and parents’ adherence to infection prevention and control and knowledge of antimicrobial stewardship: a systematic review. Am J Infect Control. 2021;49:622–639.
33. Austin Health. Nurse Initiated Febrile Neutropenia Therapy (NIFTY) Pathway. Heidelberg: Austin Health; 2018.
34. Austin Health. Antibiotic Management of Neutropenic Fever and/or Suspected Sepsis. Heidelberg: Austin Health; 2018.
35. Hunter D, McCallum J, Howes D. Defining exploratory-descriptive qualitative (EDQ) research and considering its application to healthcare. J Nurs Health Care. 2019;4.
36. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26:1753–1760.
37. Saunders B, Sim J, Kingstone T, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant. 2018;52:1893–1907.
38. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
39. Green J, Thorogood N. Qualitative Methods for Health Research. 3rd ed. London: Sage Publications; 2014.
40. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23:334–340.
41. Shenton AK. Strategies for ensuring trustworthiness in qualitative research projects. Educ Inf. 2004;22:63–75.
42. Wingard J. Treatment of neutropenic fever syndromes in adults with hematologic malignancies and hematopoietic cell transplant recipients (high-risk patients). 2021. Accessed September 10, 2021.
43. Penack O, Buchheidt D, Christopeit M, et al. Management of sepsis in neutropenic patients: guidelines from the infectious diseases working party of the German Society of Hematology and Oncology. Ann Oncol. 2011;22:1019–1029.
44. Kleinpell R. Promoting early identification of sepsis in hospitalized patients with nurse-led protocols. Crit Care. 2017;21:10.
45. Mattison G, Bilney M, Haji-Michael P, et al. A nurse-led protocol improves the time to first dose intravenous antibiotics in septic patients post chemotherapy. Support Care Cancer. 2016;24:5001–5005.
46. Bruce HR, Maiden J, Fedullo PF, et al. Impact of nurse-initiated ED sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. J Emerg Nurs. 2015;41:130–137.
47. Coates E, Villarreal A, Gordanier C, Pomernacki L. Sepsis power hour: a nursing driven protocol improves timeliness of sepsis care. J Hosp Med. 2015;10.
48. Walker ST, Grigg S, Kirkpatrick C, et al. Nurse-initiated pre-prescribed antibiotic orders to facilitate prompt and appropriate antibiotic administration in febrile neutropenia. Support Care Cancer. 2020;28:4337–4343.
49. Buckley T, Cashin A, Stuart M, et al. Nurse practitioner prescribing practices: the most frequently prescribed medications. J Clin Nurs. 2013;22:2053–2063.
50. Kilpatrick M, Bouchoucha SL, Hutchinson A. Antimicrobial stewardship and infection prevention and control in atopic dermatitis in children. Am J Infect Control. 2019;47:720–722.
51. Trubiano J, Devchand M, Holmes N, Stevenson W. Antibiotic allergy discovery and de-labelling program (AADDP) 2019. Austin Health. file:///C:/Users/jenni/Downloads/eppic_policy_antibiotic_allergy_discovery_round_final_post_clipp.pdf. Accessed November 6, 2020.

Antimicrobial stewardship; Hematology; Infection prevention and control; Neutropenic sepsis; Nurses

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