Antibiotic Stewardship in the Primary Care Setting: The Role as the APRN E. Monee’ Carter-Griffin DNP, RN, ACNP-BC Assistant Professor, Clinical Track University of Texas at Arlington

Objectives Discuss antibiotic prescribing rates in the outpatient setting. Discuss antibiotic resistance. Identify emerging threats. Discuss antibiotic stewardship Identify the role as the APRN.

Globally: Not Just a U.S. Issue 80% of antibiotics are prescribed in the outpatient setting. Half of those antibiotics prescribed are speculated to be inappropriate. Review on Antimicrobial Resistance estimates 700,000 deaths annually

Antibiotic Prescribing Rates: Outpatient

Outpatient Approximately 30-50% of antibiotic prescriptions are inappropriate. In a single year approximately 262 million courses of antibiotics are written. More antibiotics are prescribed in the winter months. Majority of antibiotic expenditures are in the outpatient setting.

Outpatient: Demographics Primary care physicians and APRNs PCPs 2x more likely to prescribe antibiotics compared to APRNs. Southern states are 2x more likely to prescribe antibiotics. Western states have the lowest prescribing rates. Midwestern states have higher prescribing rates. Eastern states have a mix.

Which antibiotics? Why? Amoxicillin and Azithromycin most commonly prescribed. Increase prescribing of broad spectrum antibiotics. Acute respiratory infections are the most common etiologies. Bronchitis, sinusitis, pharyngitis, and common cold

“Studies have indicated there is a direct correlation between antibiotic use and the extent of resistance.”

Antibiotic Misuse: Consequences

Antibiotic Misuse? Prescribing antibiotics when they are not needed Failure to narrow antibiotics Expanding duration of antibiotics longer than needed Using the wrong antibiotic and/or wrong dose

Consequences Excess healthcare costs Preventable adverse drug reactions Cause approximately 142,000 adult ED visits annually Contributes to antibiotic resistance 2 million or more people acquire antibiotic resistant infections annually At least 23,000 die from antibiotic-resistant infections

“Antibiotic misuse is the single most modifiable and important factor leading to resistance.”

Antibiotic Resistance Clostridium difficile Urgent threat Approximately 250,000 individuals require hospitalization each year At least 14,000 will die as a result of the infection

Antibiotic Resistance Carbapenem-resistant Enterobacteriaceae (CRE) Urgent threat Rising numbers in medical facilities Resistant to nearly or all antibiotics used today Neisseria gonorrhoeae Second most commonly reported infection in US

Antibiotic Resistance Serious level threats Multidrug-resistant Acinetobacter Fluconazole-resistant Candida ESBL Enterobacteriaceae Vancomycin-resistant Enterococcus (VRE) Multidrug-resistant Pseudomonas aeruginosa Methicillin-resistant Staphylococcus aureus (MRSA) Drug-resistant Streptococcus pneumoniae

Antibiotic Resistance Concerning level threats Vancomycin-resistant Staphylococcus aureus Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus

Which antibiotics? Beta lactams Macrolides Fluoroquinolones Carbapenem Penicillin Cephalosporin Macrolides Fluoroquinolones Carbapenem

Antibiotic Stewardship

“Antibiotic stewardship is a coordinated set of interventions designed to improve the use of antimicrobials.”

Antibiotic Stewardship Programs have shown to improve outcomes Save healthcare dollars Reduce the overall burden of antibiotic resistance Ensures that the patient gets the right antibiotic, at the right time, and for the right duration.

Antibiotic Stewardship: Outpatient Understand what disease processes are more likely viral versus bacterial Start with targeting certain disease processes or 1 disease Clinician and patient education Consider development of clinical pathways or protocols

What is my role as the APRN?

The APRN Outpatient and inpatient settings Reported more than 220,000 licensed nurse practitioners Estimated that 20,000 completed NP programs in 2014/2015 83% of NPs are primary care certified 55% are FNPs 95% of NPs prescribe medications in their practice area

Questions