1. 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

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

3. 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

4. Antibiotic Prescribing Rates: Outpatient

5. 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.

6. 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.

7. 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

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

9. Antibiotic Misuse: Consequences

10. 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

11. 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

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

13. 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

14. 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

15. 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

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

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

18. Antibiotic Stewardship

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

20. 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.

21. 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

22. What is my role as the APRN?

23. 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

24. Questions