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The problem
Every antibiotic prescription carries risks for the patient, including allergic reactions, C. difficile infection and other adverse effects, and contributes to antibiotic resistance in the community. Much of that use happens in outpatient care, where advanced practice registered nurses (APRNs) prescribe a growing share of antibiotics.
How much outpatient prescribing is unnecessary?
Fleming-Dutra et al. (2016) analyzed national ambulatory care surveys for 2010 and 2011. Antibiotics were prescribed at 12.6% of visits. The authors estimated that 506 antibiotic prescriptions were written annually per 1,000 people, of which about 353 were appropriate, meaning that roughly 30% were unnecessary. Acute respiratory conditions accounted for 221 prescriptions per 1,000 people a year, but only 111 of these were estimated to be appropriate. Sinusitis, suppurative otitis media and pharyngitis were the diagnoses associated with the most prescriptions.
Pharmacotherapeutic principles behind stewardship
- Right indication: most acute bronchitis, viral upper respiratory infections and many sinus infections don't benefit from antibiotics.
- Right drug: the narrowest-spectrum agent that covers the likely organism, such as amoxicillin for many cases of acute otitis media and streptococcal pharyngitis.
- Right dose and duration: the shortest effective course recommended by current guidelines.
- Right patient: checking allergies, kidney function, interactions and pregnancy status.
The core elements of outpatient antibiotic stewardship
The CDC's core elements give outpatient clinicians and facilities a framework (Sanchez et al., 2016):
| Core element | What it involves | APRN actions |
|---|---|---|
| Commitment | Demonstrating dedication to safe antibiotic prescribing | Sign and display a commitment poster in exam rooms; a practice leader takes responsibility |
| Action for policy and practice | Implementing at least one policy or practice to improve prescribing | Delayed ("watchful waiting") prescriptions for selected conditions; clinical decision support for respiratory diagnoses |
| Tracking and reporting | Monitoring prescribing and reporting it back to clinicians | Review personal prescribing rates for acute respiratory infections against peers |
| Education and expertise | Educating patients and clinicians, and ensuring access to stewardship expertise | Explain why an antibiotic won't help, suggest symptom relief, and set expectations about how long symptoms last |
Communication when patients expect antibiotics
Patients often arrive expecting an antibiotic. Effective strategies include explaining the likely viral cause in plain language, giving a specific plan for symptom relief, explaining the expected course and when to return, and offering a delayed prescription when clinically appropriate. Saying "you don't need an antibiotic" without an alternative plan tends to leave patients dissatisfied.
A practice-level project
A DNP-prepared APRN leading a stewardship project in a primary care network could:
- Measure baseline antibiotic prescribing for acute bronchitis and viral upper respiratory infections by clinician.
- Introduce peer comparison feedback reports each quarter.
- Add order-set prompts with first-line agents and durations for sinusitis, otitis media and pharyngitis.
- Train staff, including front-desk and nursing staff, in consistent messages.
- Track prescribing rates, return visits and patient satisfaction.
Conclusion
About a third of outpatient antibiotic prescriptions were unnecessary in national data. APRNs can reduce that figure by applying pharmacotherapeutic principles at each visit and the CDC's core elements across their practices.
References
Fleming-Dutra, K. E., Hersh, A. L., Shapiro, D. J., Bartoces, M., Enns, E. A., File, T. M., Jr., Finkelstein, J. A., Gerber, J. S., Hyun, D. Y., Linder, J. A., Lynfield, R., Margolis, D. J., May, L. S., Merenstein, D., Metlay, J. P., Newland, J. G., Piccirillo, J. F., Roberts, R. M., Sanchez, G. V., . . . Hicks, L. A. (2016). Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. JAMA, 315(17), 1864–1873. https://doi.org/10.1001/jama.2016.4151
Sanchez, G. V., Fleming-Dutra, K. E., Roberts, R. M., & Hicks, L. A. (2016). Core elements of outpatient antibiotic stewardship. MMWR Recommendations and Reports, 65(6), 1–12. https://doi.org/10.15585/mmwr.rr6506a1
