Antibiotic stewardship

Author(s):Norman Wright, MS, BSN, RN

Every nurse has a responsibility to prevent antibiotic resistance.

Takeaways:

  • Nurses have a key role to play in preventing infections and preserving the power of antibiotics.
  • Antimicrobial resistance is a growing danger that threatens our ability to fight future infections.

ANTIBIOTIC resistance is a growing global threat that goes beyond methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci, and other familiar multidrug-resistant (MDR) pathogens. In fact, MDR organisms (those resistant to three classes of antibiotics) are now overshadowed by carbapenem-resistant Enterobacteriaceae, which can be pan-drug resistant—resistant to all classes of antibiotics.

As a nurse, your antibiotic stewardship responsibility should be based on doing no harm, which can be accomplished with basic infection prevention practices and taking specific steps to ensure appropriate antibiotic use.

Prevention basics

When you prevent an infection, you achieve two goals: The patient isn’t harmed and antibiotics aren’t required.

Prevention includes performing proper hand hygiene and calling out anyone (nurse, respiratory or physical therapist, certified nursing assistant, physician) who fails to use proper precautions to reduce the chances of transmission. It also includes paying attention to the environment. Consider, for example, a study published in the American Journal of Infection Prevention. The researchers found that 14 days after privacy curtains were laundered and hung, five out of eight were contaminated with MRSA. How does that happen? Like this: During patient care, you notice that a curtain isn’t completely closed, so you quickly close it with your soiled gloved hand. The curtain is now contaminated. Before going on to care for the patient in the next bed, you wash your hands, don new gloves, and then close the contaminated curtain. The clean gloves are now contaminated with pathogens from the previous patient. Cross-contamination happens that quickly.

Explore your environment for similar situations and take action to correct them.

Nurse action steps

A 2016 article in American Nurse Today offered several actions staff nurses can take as members of an antibiotic stewardship team.

1. Ensure pertinent information about antibiotics is available at the point of care. This action can be rephrased as: Obtain and communicate accurate information about your patient’s symptoms to the provider. I recommend using SBAR (Situation Background Assessment Recommendation) to accurately communicate your patient’s symptoms. Too many nurses omit the “R” (recommendation) step, which can lead to an inappropriate provider order. You’re doing the physical assessment, so you have the responsibility to make an appropriate recommendation.

2. Question the antibiotic administration route. Re-evaluate and question the provider’s initial antibiotic order to determine if it’s appropriate. For example, perhaps an I.V. antibiotic can be switched to oral.

3. Reassess antibiotic therapy in 2 to 3 days. Verifying that the pathogen is sensitive to the antibiotic is imperative when the initial antibiotic is ordered before culture and sensitivity results are available. Results must be reviewed within 48 to 72 hours to determine if the antibiotic/antifungal is appropriate or needed at all. This reassessment is known as an antibiotic time out.

4. Reconcile antibiotics during all patient-care transitions. Reconciling antibiotics will help you determine if duplicate therapy has been ordered or if the culture and sensitivity results are negative for a pathogen. If the pathogen is resistant or if reconciliation shows that a narrow-spectrum antimicrobial can be substituted for a broad-spectrum one, share this information with the provider so he or she can change the initial order.

Be prepared to advocate for your patient. Some providers may resist being questioned, but your responsibility is to protect the patient from harm.

Get involved

Stay up-to-date on antibiotic best practices and participate in your state and local antibiotic stewardship programs. The American Nurses Association and Centers for Disease Control and Prevention antibiotic stewardship recommendations and video are useful guides for nursing practice. (See Antibiotic stewardship recommendations.)

Antibiotic stewardship recommendations

Your understanding of antibiotics, antibiotic resistance, and microbiology results can help ensure appropriate antibiotic use. Follow these recommendations from the American Nurses Association and Centers for Disease Control and Prevention.

Use proper technique to obtain appropriate cultures before antibiotics are started.

Consult microbiology results to help guide antibiotic selection and termination when appropriate.

Encourage starting antibiotics as soon as signs of likely bacterial infection are identified.

Advocate for good antibiotic practices in quality improvement efforts.

Initiate and participate in discussions about antibiotic use (for example, evaluate each patient’s clinical status and readiness for change from I.V. to oral therapy, when possible).

Take detailed allergy histories, especially for penicillin allergy. Educate patients and families about the importance of these histories.

Norman Wright is a nurse consultant for infection prevention in long-term and long-term acute care in Las Vegas, Nevada.

Selected references
American Nurses Association/Centers for Disease Control and Prevention. Redefining the Antibiotic Stewardship Team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the Role of Registered Nurses in Hospital Antibiotic Stewardship Practices. 2017. cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf

Manning ML. Antibiotic stewardship for staff nurses. Am Nurs Today. 2016;11(5):12-14.

Morgan SA. Strengthening nurses’ role in antibiotic stewardship. Am Nurs Today. 2017;12(10):37.

Shek K, Patidar R, Kohja Z, et al. Rate of contamination of hospital privacy curtains in a burns/plastic ward: A longitudinal study. Am J Infect Control. 2018;46(9):1019-21.

Vasina L, Dehner M, Wong A, et al. The impact of a pharmacist driven 48-hour antibiotic time out during multi-disciplinary rounds on antibiotic utilization in a community non-teaching hospital. Open Forum Infect Dis. 2017;4(Suppl 1):S272-3.

Wilson MH, Hammer C. Candida auris: Nurses’ response to an emerging threat. Am Nurs Today. 2019;14(1):16-19.

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