Excellent antibiotic stewardship is essential for preventing antibiotic resistant bacterial infection, stopping widespread disease outbreaks, and ensuring better patient outcomes. Nurse practitioners must practice strategic antibiotic prescribing and monitoring, ensuring that the most appropriate treatment protocols are employed for every patient, every time. Here, we explore the 5 “D”s of antibiotic stewardship.
Diagnosis: Know when antibiotics are necessary
An accurate diagnosis is the cornerstone of a strong treatment plan. When it comes to preventing acute and widespread antibiotic resistance, healthcare professionals must have a thorough understanding of when antibiotics are necessary to address specific infections.
Bacterial vs. viral infections
Antibiotics are only effective against bacterial infections. Many viral infections are misdiagnosed as bacterial ones and are treated with antibiotics, which delays healing, causes antibiotic resistance, and may exacerbate the progression of disease. Incorporating clinical guidelines, evidence-based tools (such as Centor criteria for pharyngitis or the CURB-65 score for pneumonia), and diagnostic testing when appropriate helps support judicious antibiotic use. NPs must do their due diligence to practice evidence-based care, conducting thorough imaging/lab testing and employing a detail-oriented mindset when evaluating patient symptoms.
Some conditions which warrant antibiotic use include:
- Bacterial pneumonia confirmed by symptom evaluation, imaging, and lab findings
- Group A streptococcal pharyngitis with diagnosis supported by a positive rapid antigen detection test or throat culture
- Urinary tract infections (UTIs) in symptomatic patients (especially women), presenting with a positive urinalysis (e.g., leukocyte esterase, nitrites, WBCs) and/or culture
- Cellulitis or erysipelas, in patients displaying localized erythema, warmth, swelling, and tenderness
- Sexually transmitted infections (e.g., chlamydia, gonorrhea, syphilis(, which require prompt diagnosis and appropriate antimicrobial therapy to prevent complications and transmission.
Related: Antimicrobial Essentials Package
Drug selection: Discerning the most appropriate antibiotic
Once an accurate diagnosis is made, an NP must opt for the most effective antibiotic for the patient’s specific needs. The ideal drug targets the likely pathogens with the narrowest effective spectrum, minimizing collateral damage to the microbiome and reducing the risk of resistance. Empiric therapy should be informed by clinical guidelines, local antibiograms, and patient-specific factors such as allergy history, renal function, and recent antibiotic use. Broad-spectrum agents (e.g., fluoroquinolones, carbapenems) should be reserved for cases where resistance is likely or confirmed.
Dosage: How much is too much?
Use this checklist for determining the most effective dosage for your patient.
- Correspond dose to infection type and severity
- Consider location of infection
- Choose doses based on the person’s BMI or other weight-based metric: This is especially important for pediatric patients, and those that are severely over or underweight
- Be mindful of organ function (overprescribing may affect kidney health)
- Factor in the PK/PD of specific meds
- Employ therapeutic drug monitoring (TDM) if needed
Duration of antibiotics: Timing is everything
The round of antibiotics prescribed to a patient should be tailored according to their health needs and the severity of the infection that needs to be addressed. Evidence increasingly supports shorter courses for many common infections, which can be equally effective while reducing the risk of resistance, side effects, and disruption to the microbiome. Overly long treatment durations are a common cause of unnecessary antibiotic exposure. Nurse practitioners should follow clinical guidelines and remain up to date with evolving recommendations that often favor 3–7 day courses for many uncomplicated infections. The key is to treat until the infection is resolved—not any longer. Patient education plays an important role, especially in encouraging adherence to shorter, guideline-supported courses.
Related: Rx Essentials: Antimicrobial Prescribing Update
Deescalation: Narrowing the scope
As more clinical findings become available, it’s important for the care provider to tailor treatment plans accordingly. Deescalation is a core principle of antimicrobial stewardship and helps reduce resistance, toxicity, and unnecessary costs. Once culture results, sensitivities, or clinical progress confirm a more targeted or less aggressive approach is appropriate, therapy should be adjusted accordingly. This includes switching from broad-spectrum to narrow-spectrum agents, stopping unnecessary combination therapy, or even discontinuing antibiotics altogether if no infection is confirmed. Nurse practitioners are in a key position to reassess therapy during follow-up visits, rounds, or transitions of care.
By employing the 5 D’s of antibiotic stewardship, you can play an essential role in harm reduction across a spectrum of healthcare settings.
