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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 4-9

The more the merrier: Acute care advanced practice registered nurses and antimicrobial stewardship


1 Department of Nursing, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
2 The Ohio State University Wexner Medical Center; Department of Pharmacy, The Ohio State University College of Pharmacy, Columbus, Ohio, USA

Date of Submission12-Apr-2019
Date of Acceptance12-Aug-2019
Date of Web Publication27-Mar-2020

Correspondence Address:
Dr. Anthony T Gerlach
Room 368, Doan Hall, 410 West Tenth Ave, Columbus, Ohio 43210
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_22_19

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  Abstract 


In the last decade, there has been a dramatic increase in advance practice registered nurses (APRNs) in the acute care setting. In 2017, the Joint Commission issued antimicrobial stewardship (AMS) standards for the acute care setting. The role of the APRNs has not formally been recognized in the guidelines for implementing and operative AMS programs. Regardless, APRNs are increasingly performing essential roles in antibiotic stewardship, and the aim of this review is to describe areas APRNs can impact antibiotics stewardship. Articles that described AMS process were indexed from PubMed. APRNs have expertise in managing and coordinating care for across many clinical conditions and are able to improve the quality of care and improve AMS.
The following core competencies are addressed in this article: Medical knowledge, Patient care.

Keywords: Advance practice registered nurse, antibiotic resistance, antimicrobial stewardship, antimicrobial stewardship program


How to cite this article:
Byrd CA, Gerlach AT. The more the merrier: Acute care advanced practice registered nurses and antimicrobial stewardship. Int J Acad Med 2020;6:4-9

How to cite this URL:
Byrd CA, Gerlach AT. The more the merrier: Acute care advanced practice registered nurses and antimicrobial stewardship. Int J Acad Med [serial online] 2020 [cited 2020 Sep 26];6:4-9. Available from: http://www.ijam-web.org/text.asp?2020/6/1/4/281453



Antibiotics revolutionized clinical care, and the wide use of them is one of the most important developments in modern medicine.[1] As antibiotics were first derived from other organisms, resistance has always been a concern with penicillin-resistant Staphylococcus aureus first being detected in clinical specimens in 1945. In fact as early as 1945, Sir Alexander Fleming warned against the unnecessary use of antibiotics cautioning about the risk of resistance.[1] On May 2015, the Centers for Disease Control determined that approximately 30% of all antibiotics in the United States used in acute care hospitals are unnecessary and prescribed inappropriately.[2]

Antimicrobial resistance has emerged as a significant patient safety and healthcare quality threat worldwide.[1] It is estimated that over 700,000 people die every year from a resistant bacterial infection; it has been predicted that over 10 million people will fall victim to resistant infections by the year 2050.[3],[4] In 2015, the World Health Organization developed a Global Action Plan on antimicrobial resistance, and a key objective is to optimize the use of antimicrobial medicines. In 2017, in addition to this effort, The Joint Commission (TJC) recently issued new antimicrobial stewardship (AMS) standards.[5] First and foremost, these standards establish AMS as an organizational priority. Key in these standards are educating staff, including licensed independent practitioners, involved in antimicrobial ordering, dispensing, and administration and monitoring about antimicrobial resistance and prescribing practice.

Along with the implementation of AMS practice, health-care systems have also seen a dramatic increase in the use of advanced practice registered nurses (APRNs) in all areas of health care delivery. As of June 2017, the American Association of Nurse Practitioners states that there are more than 234,000 APRNs licensed in the United States with half holding hospital privileges.[6] This is an increased from 2014 where there were over 189,000 APRNs with 45% holding hospital privileges.[7] APRNs hold prescriptive privileges, including controlled substances in all 50 states and the District of Columbia. On average, APRNs write 23 prescriptions a day.[6] In the outpatient setting, APRNs are more likely to prescribe antibiotics than “physician-only” visits for both overall visits (17% vs. 12%, P < 0.001) and acute respiratory infection visits (61% vs. 54%, P < 0.001).[8] No data are available on antibiotic prescribing for hospitalized patients by APRNs or by specialty.

As there is a paucity of data, the aim of this paper was to develop a systematic literature review of the role of APRNs on AMS in the acute care setting. A PubMed search was conducted for articles that describe the process on AMS and APRNs or Advanced Practice Provider (APP). Key terms used in the first search included: AMS program, or antibiotic stewardship program (ASP), and APRNs or APP. When no articles were found a second search using AMS program or ASP and process was conducted. Searches were conducted on November 2018, April 2019, and August 2019.

APRNs have an increasing role in antibiotic prescribing in both the outpatient and acute care hospital setting [Table 1]. Some strategies that have been suggested for outpatient APRNs prescribing education can also be applied to the acute care settings.[7] These include advancing knowledge, optimizing antibiotic prescribing performance and practice, and adopting antibiotic stewardship action into the practice setting.[7] A recent publication from Goff et al. discusses habits of highly effective AMS programs, and APRNs can be integrated into these initiatives and more importantly play key roles within the ASP team.[4] These recommendations include education to prescribers on antimicrobial resistance and AMS including encouraging face-to-face interactions. Having APRNs understand organizational approved multidisciplinary protocols such as antibiotic formulary restrictions, dose optimization, disease-specific protocols and pathways (i.e., Clostridioides difficle protocol), and taking action on improvement opportunities identified by antimicrobial programs including allergy assessment and rapid diagnostic testing.
Table 1: Role of advance practice registered nurses in antimicrobial stewardship

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Antibiotics are universally prescribed by clinicians, including APRNs, without regulation or certification.[4] One key strategy of the 2017 TJC Antimicrobial Stewardship Standard includes educating staff involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and AMS practice [Table 2].[5] Continuing education about antimicrobial resistance and appropriateness is paramount for successful multidisciplinary ASP teams, with didactic education sessions alone providing limited impact for sustained effect in changing antimicrobial prescribing.[4],[9] Goff et al. recommends annual education through online and case-based learning on AMS competencies, additionally encouraging face-to-face interaction between team members, including APRNs and pharmacists.[4] This face-to-face interaction leads to immediate actions on patient care, provides real-time disease-specific education, and helps develop a rapport with other disciplines.[10]
Table 2: Advanced practice registered nurse activities compared to other health-care professionals in antimicrobial use process

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Anecdotally, APRNs report a lack of confidence in antibiotic prescribing, especially in the setting of the complicated critically ill patient. This may explain why APRNs are more likely to prescribe antibiotics than physicians in the outpatient setting. At the time of writing, there are no data available on APRNs prescribing in the hospitalized patients. In general, graduate APRNs education dedicates fewer than 10 h on antimicrobial therapy and 52% of the programs did not offer a course of microbiology.[11] A study by Abbo et al. looked at APRNs' attitudes, perceptions, and knowledge surrounding antibiotic stewardship which demonstrated a need for continued education in the areas of microbiology, appropriate antibiotic selection, and antibiotic resistance.[11]

Education on AMS is paramount with the TJC AMS Standard. Regardless of practice, APRNs in the acute care setting are part of the interprofessional process of antimicrobial use, including prescribing, monitoring, and education. APRNs need to familiarize themselves with the medication use process and partner with key individuals. They should develop and foster relationships with other members in the antimicrobial use process, including infectious disease team members, microbiologists, and pharmacists. Likewise, the APRNs need to educate themselves on the importance of being good stewards of antibiotic usage, develop a firm understanding of antibiotic resistance, increase knowledge of the resources available for reference (i.e., hospital antibiogram), and to advance a collaborative approach in the care of the complicated patient. They should also learn how to modify initial antibiotic selection based on the preliminary gram stain results and learn the basics of rapid diagnostic tests. In addition, the APRNs should learn how to apply antibiotic susceptibility testing and reporting including assessing the minimal inhibitory concentration which guides the provider on a targeted antibiotic selection based on very specific data. Finally, APRNs should be educated on the appropriate duration of therapy, emphasizing the importance of initiating antibiotic stop dates as soon as they are determined through the use of literature review.

While the critical care APRNs plays a vital role in the proper prescribing of and the de-escalation of antibiotics, another important facet to decrease multidrug resistance is the role of infection preventions. For example, while the incidence of C. difficile infections has decreased in Western Europe, it has plateaued at historic highs in the United States and has caused many hospitals to evaluate risk factors associated with acquiring this infection.[12] Literature has shown that the use of proton pump inhibitors (PPI) has been linked to an increased risk for the development of C. difficile infections.[13],[14] The APRNs can be integral in the mitigation of this as a risk factor. Patients are often admitted to the hospital on these medications with no clinical indication. In the light of critical illness and antibiotic exposure, any further measures that can strive to decrease the risk of a hospital-acquired infection will only serve to benefit patients. Therefore, the APRNs and pharmacy team in unison are able to perform a thorough medication reconciliation and assess the necessity of medications to reduce patient risk for obtaining a hospital-acquired infection.

Another basic role that the APRNs can accomplish is obtaining an accurate history, including patient's medication allergies and their reaction. Many health-care practitioners have realized that the drug allergies in electronic medical records are unreliable.[15] Between 10% and 20% of patients may have a reported beta-lactam allergy.[16],[17] Studies have found that >90% of patients tested do not have a true beta-lactam allergy and can safely receive these antibiotics.[15],[18],[19] Recently, two studies have been published associating beta-lactams allergy with worse patient outcomes in patients with surgical site infections as well as those who develop infections with underlying hematologic malignancies.[17] Blumenthal et al. reported that the presence of a beta-lactam allergy in patients who received surgery at a single institution had a 51% increase in surgical site infection primarily due to the substitution of nonbeta lactams for a cephalosporin as prophylaxis.[17] Huang et al. reported that hospitalized patients with hematologic malignancies requiring antibiotics who had a reported beta-lactam allergy had higher, hospital length of stay, 30- and 180-day mortality, 30-day readmission rate, and development of C. difficle.[16]

An essential process needs to focus on updating electronic medical records.[15] Not surprisingly, Blumenthal et al. also reported that patients with self-reported beta-lactam allergy were also more likely to report a cephalosporin allergy, vancomycin allergy, and more allergies overall.[17] The phenomenon of some patients attributing any unwanted effect like nausea or a yeast infection to an allergy complicates clinical care.[15] Not assessing the validity of an allergy up front, can lead a hurried clinician to pick a less effective option placing the patient at increased risk of harm. The APRNs are in an optimal position to get a detailed history and update medical records so inaccurate allergies will not persist within the electronic medical record.

For too long, there has been a one size fits all to antibiotics prescribing, especially in the hospitalized patient. The combination of vancomycin and piperacillin/tazobactam is a classic example as it targets many pathogens, but it is not without risks. In recent meta-analyses, this combination is associated with approximately a three-fold increase in nephrotoxicity, potentially placing patients at risk when used in ubiquitously.[20],[21] There is a perception that methicillin-resistant S. aureus (MRSA) needs to be covered in most hospitalized patients, even for community-acquired infections. A study of five acute care hospitals in Detroit, MI comprising 558 patients that the rate of MRSA was only 7%.[22] The 2014 skin and soft-tissue infection clinical practice guidelines only recommend vancomycin for severe infections.[23] Similarly, in a 2016 surveillance study of 2259 adults hospitalized for community-acquired pneumonia in five American hospitals over 2.5 years, the incidence of MRSA was 1% despite nearly one-third receiving anti-MRSA treatment.[24] For hospital-acquired pneumonia, a recently meta-analysis concluded that MRSA nasal screening has a high specificity and negative predictive value to rule out MRSA pneumonia.[25] In addition, data suggest that empiric vancomycin is not needed for intra-abdominal infections.[26] An antibiotic educated APRNs can take the lead in conducting a detailed medical history, including reviewing the past cultures and stopping inappropriate empiric therapy when not indicated, convey this to the team and more importantly begin to disseminate the antibiotic stewardship concept to others within an organization.

In addition to empiric prescribing, the ordering of appropriate tests for identification and subsequent antimicrobial susceptibility testing is paramount. Traditional or standard techniques for identifying bacteria are based on phenotypic methods and typically take 48–72 h to provide final results.[27] Rapid diagnostic test is an emerging technology that typically decreases the time to diagnosis and therefore, appropriate antibiotics therapy by 24–40 h.[27] Initially, rapid diagnostics were used for blood infections, but have since expanded to other infections, including panels for respiratory sputum and spinal fluid.[28] The APRNs must be cognizant of how and when to order testing, as well as have the skills to interpret the results. The ability to order and interpret the rapid diagnostic testing is another way the APRNs can be influential within an ASP.

Much of the dialogue surrounding antibiotic usage is focused on antibiotic selection. Along with appropriate antibiotic selection, the appropriate dosage of antibiotics in the era of antibiotic resistance is of increased importance. It is known that overdosing antibiotics places patients at risk for adverse effects; under-dosing has the potential to contribute to morbidity, mortality, and worsening drug resistance. Both pathogen-specific and patient-related factors can alter pharmacokinetic and pharmacodynamic targets and affect clinical outcomes. Problematic bacteria such as Pseudomonas aeruginosa or Acinetobacter species, often have multiple resistance mechanisms leading to elevated minimum inhibitory concentrations.[29] As a result, there is a new classification called susceptible dose-dependent, basically stating higher dosing is required to achieve a clinical response such as cefepime 2 g intravenous (IV) every 8 h for an  Escherichia More Details coli isolate with a mean inhibitory concentration of 8 mg/L.[30]

A large majority of antibiotics are eliminated renally, and recently, a concept of augmented renal clearance has evolved. Augmented renal clearance is typically described as a creatinine clearance >130 mL/min and is associated with subtherapeutic drug concentrations and may lead to decrease clinical success.[31] Optimizing administration of antibiotics by use of continuous infusion or extended infusions, typically over 3–4 h, has been shown to improve outcomes.[32] For patients with augmented renal clearance, these strategies might not be enough especially in the setting of a P. aeruginosa infection. Newly emerging data suggest the patients with augmented renal clearance even extended infusion piperacillin/tazobactam 4.5 g every 6 h may be required to achieve pharmacokinetic and pharmacodynamic targets.[33] APRNs should have a basic understanding of the factors that affect antibiotic dosing and partner with infectious disease specialist and pharmacists to maximize dosing while minimizing adverse effects.

There has been increasing the use of serial monitoring of biomarkers to aid in the diagnosis of sepsis and help promote AMS.[34],[35] Of the over 175 biomarkers that have been studied, only C-reactive protein and procalcitonin are commonly used, but both have pitfalls.[35] C-reactive protein is not specific for infection, has a relatively long half-life of 19 h that peaks 24-24 after insult.[34] Conversely, procalcitonin has a quick peak and rapid decrease, but only has a 77% sensitivity and 79% specificity.[36] Like C-reactive protein, it is also increased in states of inflammation such as cardiac arrest or after surgical procedures.[36] Procalcitonin is one of the most studied biomarkers, and most agree that it should not be used to diagnose infection.[34],[36],[37] Currently, studies have yielded mixed results in decreasing antibiotic exposure.[36],[37],[38] There is currently no universal or usable biomarker to help guide therapy, and if biomarkers are used, they should be used in conjunction with the clinical examination.[36],[37]

Rapid diagnosis test is increasingly common and has demonstrated to have clinical and economic success when used in conjunction with AMS teams.[4] These tests have the potential to provide collaborative opportunities, improve patient outcomes, and decrease antimicrobial utilization when clinicians have the appropriate education.[4] APRNs need to work with AMS teams to help ensure the tests are being ordered appropriately and changing therapy in a timely manner based on the results.

Changing antibiotics from IV to oral or enteral route is one of the tenets of AMS. There are many potential benefits for the patient, such as less pain and risk with the need for IV access, health-care team, and hospital.[39] The use of oral antibiotics has been associated with earlier discharge from the hospital.[39] A common misconception is that IV antibiotics are associated with better outcomes. In a meta-analysis of patients with moderate-to-severe community-acquired pneumonia switching to oral antibiotics within 2–4 days appeared to be as effective as continuing IV therapy.[40] In a surgical intensive care unit population with pneumonia, Elofson et al. also demonstrated similar efficacy when antibiotics were switched to enteral administration by day 4 of treatment.[41] Inpatient APRNs should determine if IV antibiotics can be switched to enteral daily.

The use of a multipronged system to address the national crisis of multidrug resistance is essential to the decrease the widespread epidemic of antibiotic resistance. The APRNs can play a significant role in AMS but may need more education to accomplish these important tasks. The APRNs should partner with other teams such as infectious disease and pharmacy. The APRNs and pharmacy teams are poised to fill this need within the organization. In addition, the use of the critical care transition to practice APP Fellowship has allowed new APRNs providers to obtain the skills necessary to function in this way within the teams in which they provide care. As informal antibiotic stewards, we have been able to disseminate this information to many within the organization.

Ethical conduct of research

This manuscript represents a literature review. Because this project involved no experimental design, the Institutional Review Board approval was not required. Applicable EQUATOR Network (http://www.equator-network.org) guidelines were followed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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