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ANTIMICROBIAL STEWARDSHIP &

THE NURSE PRACTITIONER

Pamela Brown Stewart, DNP, APRN, FNP-BC 30th Annual Texas Nurse Practitioner Conference

Dallas, Texas

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Antibiotics have been referred to as the most

significant therapeutic intervention in the history of medicine1.

§ 269 million antibiotic prescriptions dispensed from U.S. outpatient pharmacies in 20152 § 838 antibiotic prescriptions per 1,000 persons § Enough for 5 out of every 6 people to have one antibiotic prescription/year § At least 30% were unnecessary (80.7 million) § 31.5 million Fluoroquinolone (FQ) courses dispensed outpatient in U.S.3

  5% were for conditions that did not require antibiotics   19.9% for conditions where FQ are not recommended first line therapy

BACTERIA VIRUS

FUNGUS PARASITE

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Stewardship is an __________ that embodies the responsible planning and management of resources.4

refers to coordinated interventions designed to improve and measure the use of antimicrobials by promoting the selection of the optimal drug regimen, dose, and duration of therapy and route of administration. 4

Antimicrobial seek to achieve optimal clinical outcomes related to antimicrobial use to:

§ Minimize toxicity and other adverse drug effects § Reduce the cost of healthcare for infections § Limit the selection for antimicrobial resistant strains.4

SOURCE: Infectious Disease Society of America (2011). Issue supplement, volume 52, no.5, pages S397-5428.

L Resistance

L Limited new agents in development

L Multi-drug resistance

L Biofilm

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Top Ten Patient Reasons for Requesting Antibiotics

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Reasons Clinicians Prescribe Antimicrobials When Not Required

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Tip #1: Have patient education materials accessible.

Tip #2: Know the “red flags” for the presenting problem. § Pharyngitis – Excessive drooling, unilateral facial swelling, persistent greater than 6

weeks, airway compromise, unable to open jaw

§ Conjunctivitis – severe eye pain, visual changes, immunocompromised

§ Cellulitis – Fever, rapidly spreading redness, crepitus, pain disproportionate to wound/injury, recent wading in the Gulf of Mexico, necrosis

Tip #3: Know the relevant statistics.

Sinusitis IDSA Media Contact 03/21/12 • Antibiotics are prescribed far too often for sinus infections: only 2 to 10 percent are caused by bacteria,

requiring treatment with antibiotics, suggest new guidelines released by the Infectious Diseases Society of America (IDSA).

• Nearly one in seven people suffer from sinus infections every year, but 90 to 98 percent are caused by viruses.

• The guidelines help doctors distinguish between viral and bacterial infections so they know when to prescribe antibiotics.

• Amoxicillin-clavulanate should be prescribed for bacterial sinus infections, due to increasing resistance against amoxicillin.

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Tip #4: Develop your Talking Barbie responses

PATIENT SAYS NP RESPONSE AVOID SAYING The color of the stuff coming out my nose is green and my mother taught me……..

“Let me show you some information I have about what the color of drainage means.”

Treatment is not made on the color of nasal drainage.

My husband has bronchitis and I don’t want to catch….

“Unfortunately, antibiotics have not been shown to prevent upper respiratory infections.’

Using an antibiotic for a virus is like offering a fire extingisher to someone who is drowning.

An antibiotic will not help a viral infection and could increase your risk of becoming colonized with antibiotic-resistant bacteria and developing side effects that could make you feel worse.”

This is just a virus.

I am going on a cruise… “You need and deserve the correct treatment. If I give you a antibiotic for a viral illness there are chances you could develop more problem from the drug’s potential side effects.”

The potenil side effects of antibiotic increase your risk of dying from a cardiac arrhythmia threefold.

Special life event “Viral infections can make you feel sick and uncomfortable. Unfortunately antibiotics won’t help youand could actually do harm”

Short –term Stress “I understand your situation and your desire for a quick end to your illness but taking an antibiotic I not going to help.”

I am not a social worker.

Long-term stress “It sounds like you are feelin stressed. Would you like to talk about what is going on?

I am not a psychiatist.

Good Old Days “You are right, in the past antibiotics were prescibe for symptomd like yours. Science tells us it not he right thing to do.”

Things change and ou justhave to get used to it.

You aren’t even a real doctor. I need to see a real physician. I want to speak to the manager!!

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How NPs Can Be Antimicrobial Stewards

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RESOURCES AND REFERENCES

1. Davis, J. & Davies, D. (2010). Origins and evolution of antiibiotic rsistance. Microbiology and Molecular Biology Reviews, 73(3), 417-433.

2. Centers for Disease Control and Prevention. Outpatient Antibotic Prescriptions –United States, 2015

3. Kabbani,S., KHersh, A.L., Shapiro, D.J., Fleming-Dutra, K.E., Pavi, A.T.,& Hick, L.A. (2018). Opportunities to improve fluroquinolone prescribing in U.S. ault ambulatory care visits, Clinical Infectious Disease, 67(1) 134-136.

4. Centers for Disease Control and Prevention (2013) Antibiotic resistance threts ite United States

Centers for Disease Control and Prevention (2018) Antibiotic/Antiicrobial Resistance https://www.cdc.gov/drugresistance/ Accessed 8/1/2018.

CDC. Antibiotic Use in the United States (2017). Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2017.

Chesanow, N. (2016). 10 ways to say no to patients and keep them smiling. Medscape, February 17.

Hicks, L.A. et al. (2015). U.S. outpatient antibiotic prescribing patterns according to geographics, patient population and povider specialty in 2011. Clinical Infectious Disease, 60(9), 1308-16.

Wong, D.M., Blumberg, D.A., & Lowe, L.G. (2006) Guidelines for he use of antibiotics in acute respiratory infections, American Family Physican, 74(6), 956-966.