Antibiotics, a miracle of modern medicine, have saved countless lives since their invention. However, the microbes that these drugs target also evolve over time. This is known as antimicrobial resistance, or AMR. The more we take antibiotics, the more resistant we become to them, and the less effective they become for everyone. The simple solution is to take antibiotics only when strictly necessary, but the reality is more complicated.
The coordinated effort to ensure that antibiotics are prescribed with and taken correctly is called antibiotic (or antimicrobial) stewardship. It’s a two-way street with implications for both prescriber and patient. Proper stewardship means that clinicians should only prescribe antibiotics when necessary. At the same time, patients should adhere to the schedule of antibiotics prescribed by a clinician.
For nurse practitioners, the biggest challenge to proper antibiotic stewardship often occurs in the exam room: a patient with a cold, sinus pressure, or sore throat who is convinced they need antibiotics. It’s a familiar (and sometimes exhausting) part of practice. While responsible stewardship is critical for public health on a grand scale, the day-to-day reality is that NPs must contend with patient satisfaction and expectations. Doing so requires careful communication.
The Real Challenge: Patient Requests
Many patients still believe antibiotics are a cure-all for any illness. In 2016, the CDC found that up to one-third of antibiotic prescriptions in the U.S. are unnecessary, with much of that pressure driven by patient expectations. These conversations are difficult to have, and some patients don’t see the big picture of antibiotic resistance the way you do.
As NPs, saying “no” isn’t always simple. It can feel like you’re letting the patient down, risking dissatisfaction, or setting yourself up for conflict. When a patient is especially persuasive or confrontational it can be difficult to just say “no,” leading some NPs to prescribe just to get the appointment over with in a timely manner.
The result? Some NPs overprescribe just to avoid the battle, especially when under time pressure. But these interactions are also opportunities to educate patients on the importance of proper antibiotic use and to model responsible prescribing.
The ‘Four Moments’ Approach
The Agency for Healthcare Research and Quality, a division of the Department of Health and Human Services, recommends a “four moments” approach to clinical decision-making when it comes to prescribing antibiotics and managing patients who are currently taking them. View the resource here.
Moment 1: Does my patient have an infection that requires antibiotics?
Moment 2: Have I ordered the appropriate cultures before starting antibiotics?
Moment 3: Can I stop antibiotics, narrow the treatment, or change to oral therapy?
Moment 4: How long does the patient need to take these antibiotics?
This framework is designed for acute care, but has applications for all specialties in which antibiotics are prescribed. It challenges clinicians to take control of prescribing antibiotics as a conscious choice rooted in decision-making, while also keeping patient health at the center of the equation.
Communication in Action
Nearly every NP has been in the room with a patient who insists antibiotics are the only way forward. Sometimes, what patients really want isn’t what they want to hear. Below are some situations you might recognize, along with a modifiable script that you can use to keep the dialogue empathetic while also promoting responsible stewardship.
- “Last time I had a cold, antibiotics fixed me right up. Can you just write me a prescription?”
NP: I understand wanting to get better fast, but antibiotics don’t help with viral infections like most colds and flus. What we can do is talk through what will actually help you feel better while your body fights it off.
- “My kid has a sore throat and always gets strep around this time of year. Can we go ahead and start antibiotics now?”
NP: The best way to help is to test first. If it’s strep, we’ll start treating it immediately. If not, antibiotics could make your child feel worse without solving the problem.
- “I paid for this visit. Can’t you just give me something, just in case?”
NP: I only prescribe antibiotics when a bacterial infection is confirmed. Let’s come up with a plan for what to watch for and how we’ll follow up if things don’t improve within [X] time frame.
- “But my friend who had these same symptoms got antibiotics for it.”
NP: My job is to make sure you get the safest and most effective treatment for what’s going on right now. For that, I’d recommend running some tests. Once we know, we can figure out what treatment will work best for you.
These conversations take time and emotional energy that you may already be running short on. Some patients will grumble that you aren’t doing enough to help them by not offering antibiotics immediately, and that’s okay. Antibiotic stewardship is part of the therapeutic relationship, and NPs who prioritize it are helping to protect patients today while also helping fight resistance tomorrow.
This content is intended for educational purposes only and does not substitute for clinical judgment. Treatment decisions should be based on individual patient needs, professional guidelines, and a comprehensive clinical evaluation.
