Antibiotic resistance threatens the health of individuals worldwide. Globally, it is estimated that over 39 million deaths will be attributable to antibiotic resistance between 2025 and 2050 (Naghavi et al., 2024). Antibiotic resistance refers to the ability for bacteria, viruses, fungi, and parasites to thrive in the presence of drugs designed to kill them (Salam et al., 2023). Infections caused by antibiotic resistant organisms lead to an increased length of treatment, increased costs, and higher rates of morbidity and mortality (Prestinaci et al., 2015).

In response, international and national agencies have prioritized coordinated action to curb antibiotic resistance. The World Health Assembly adopted a global action plan in 2015 to address antibiotic resistance (World Health Organization, 2015), and the United States will release its third National Action Plan for Combating Antibiotic-Resistant Bacteria in 2026 (CDC, 2024). Multidisciplinary engagement in antibiotic stewardship is at the crux of these efforts (CDC, 2019; World Health Organization, 2022). Antibiotic stewardship refers to the coordinated efforts within a healthcare team to improve the dose, duration, route, and type of antibiotic used for treatment, with the goal of reducing antibiotic resistance (Shrestha et al., 2025).

Prominent organizations worldwide call on nurses to take an active role in antibiotic stewardship (“Antimicrobial Stewardship in Australian Health Care: 2018.,”, 2019; CDC, 2019; Commission Notice — EU Guidelines for the Prudent Use of Antimicrobials in Human Health, 2017). Yet, evidence examining the readiness of prelicensure nursing students to participate in antibiotic stewardship is limited. In a single-site study from Australia, Bouchoucha et al. (2021) assessed students' perceptions of the nurses' role in antibiotic stewardship and found substantial knowledge gaps. Among 321 respondents, only 143 (45%) were familiar with the term antibiotic stewardship and 227 (71%) self-reported their knowledge of antibiotic stewardship as either none or limited (Bouchoucha et al., 2021). In the United Kingdom, Courtenay et al. (2025) similarly identified deficits among third-year nursing students, particularly in interpreting microbiology results and understanding the role of broad-spectrum antibiotics in promoting antibiotic resistance. In the U.S., Manning et al. (2022) found that an educational intervention improved students' knowledge of antibiotics, appropriate prescribing principles, and antibiotic resistance. Collectively, these studies illustrate consistent gaps in antibiotic stewardship knowledge among prelicensure nursing students and highlight the potential for educational interventions to strengthen student preparedness.

In 2019, the Centers for Disease Control and Prevention (CDC) outlined specific ways nurses can contribute to hospital-based antibiotic stewardship programs, including diagnostic stewardship (e.g., ensuring appropriate urine cultures and C. difficile testing) and improving the assessment of antibiotic allergies (CDC, 2019). To the best of our knowledge, no national study has evaluated the preparedness of U.S. prelicensure nursing students to perform these activities as part of hospital-based antibiotic stewardship. This gap is critical, given that nearly 90% of graduates enter hospital settings upon completion of their programs (Church et al., 2025). Similarly, hospital-based antibiotic stewardship programs have been mandated by the Joint Commission and the Centers for Medicare and Medicaid Services since 2017 and 2020, respectively [(CMS, 2019) & (The Joint Commission, 2025)], underscoring the importance and financial imperative of hospital-based antibiotic stewardship programs.

Diagnostic stewardship focuses on ensuring the appropriate use of microbiological tests to optimize antibiotic treatments. Current diagnostic guidelines by the Infectious Disease Society of America recommend that C. difficile testing should be targeted in patients with unexplained, new onset of ≥3 unformed stools in 24 h (McDonald et al., 2018). There has been a long-standing myth that individuals can detect a C. difficile infection by the smell of the stool, however this is not supported in the literature (Rao et al., 2013). C. difficile is present asymptomatically in the stool of approximately 7% to 26% of adult inpatient individuals (Murad et al., 2016), underscoring the need for the proper assessment of symptoms to guide C. difficle testing.

Similarly, diagnostic criteria for ordering a urine culture include signs and symptoms of a urinary tract infection such as urgency, dysuria, pelvic discomfort, and acute hematuria (CDC, 2019). Asymptomatic bacteriuria is defined as the presence of bacteria in a properly collected urine sample in an individual presenting with no signs or symptoms of a urinary tract infection (Givler & Givler, 2025). Inappropriate C. diffile testing and urine culturing has the consequence of obtaining false positives and promoting the unnecessary use of antibiotics and antibiotic resistance (Litvin et al., 2009; Shallcross & Davies, 2014). By knowing when and when not to obtain cultures, nurses may optimize microbiology cultures and advance diagnostic stewardship.

The CDC also calls upon nurses to improve the evaluation of penicillin allergy (CDC, 2019). Approximately 10% of the US population reports a penicillin allergy, however less than 1% of the population has a true IgE mediated reaction (Stone, 2023). The clinical and public health implications of non-verified penicillin allergies are substantial. Hospitalized patients who carry a penicillin allergy label experience longer hospital stays, increased reliance on broad-spectrum antibiotics, and a heightened risk of developing methicillin-resistant Staphylococcus aureus and C. difficile infections (Anton-Vazquez et al., 2024).

Current CDC guidance emphasizes that appropriate evaluation of suspected penicillin allergies includes a detailed history, physical examination, and, when indicated, skin testing or a graded challenge (CDC, 2019). The IgE antibodies that are responsible for the reaction to penicillin decrease overtime and at a rate of around 10% per year (Patterson & Stankewicz, 2023). True anaphylactic reactions to penicillin may include urticaria, angioedema, respiratory compromise, and hypotension (Poowuttikul & Seth, 2019). By obtaining a thorough penicillin allergy history and distinguishing true allergic reactions from non-allergic symptoms, nurses play a key role in improving the evaluation of penicillin allergies. Despite these clearly defined expectations, the readiness of U.S. prelicensure nursing students to assume these roles has not been examined. Therefore, this study aimed to evaluate the readiness of U.S. prelicensure nursing students to participate in antibiotic stewardship.