In the community clinic where I volunteer, we provide services to the uninsured and underinsured, many of whom are migrant farm workers. They often don’t speak English and the cultural differences are many. I’ve learned much from caring for these patients. With my background in critical care, I was not use to patients who could walk and talk, let alone seek care for wounds and work-related injuries in addition to their primary care needs.

One patient came in with several wounds on his feet. His daily work required him to be on his feet for long hours working in the fields. He wore heavy boots that were not waterproof and by the look of his socks, it was difficult for him to keep his feet clean and dry. The wounds were inflamed with yellow drainage, hot and painful. With help from an interpreter, we asked the usual questions – When did you first notice these wounds? Do you have them anywhere else? Did you ever have these before? Have you tried any treatment?

Through our conversation, we learned that he had been taking penicillin. Great, we thought, he had already seen a health care provider and the wounds had already been cultured. Wrong. He explained that the grocer in his neighborhood had given him some pills. He showed us the package and sure enough, it was a form of penicillin. He had purchased it at his local market.

I was shocked. To me, antibiotic stewardship meant holding off on antibiotics for my kids with ear pain, waiting for a respiratory virus to declare itself as viral or bacterial, or waiting for culture results. I have been naïve in my lack of knowledge that antibiotics are out there – in grocery stores, in medicine cabinets (“saving some pills for next time”), and in neighbors’ and friends’ pockets or purses. Wow!

A recent review published in the Annals of Internal Medicine found that the prevalence of nonprescription antibiotic use varied from 1% to 66%, depending on population characteristics. Factors that contributed to use of nonprescription antibiotics were easy access through markets or stores that obtain antibiotics internationally for under-the-counter sales, difficulty accessing the health care system, costs of physician visits, long waiting periods in clinics, and transportation problems (Grigoryan et al, 2019).

This is an urgent public health concern and my new experiences in the community setting have really opened my eyes to this problem. We can do better – but how? In 2017, The American Nurses Association and the Centers for Disease Control and Prevention published 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. Four key questions are addressed by the work group:

1. What are the roles that bedside nurses can and should play in working to improve antibiotic use?
2. What education and training resources are needed to help nurses perform these roles?
3. How can we engage nurses more and encourage them to participate in antimicrobial stewardship programs?
4. What can we do to engage nursing leaders in stewardship efforts?

I encourage you to download the white paper (it’s free). Review the suggestions related to each of these questions and learn how you can make a difference.

References:
Grigoryan, L., Germanos, G., Zoorob, R., Juneja, S., Raphael, J., Paasche-Orlow, M., & Trautner, B. (2019). Use of Antibiotics Without a Prescription in the U.S. Population: A Scoping Review. Annals of Internal Medicine. doi: 10.7326/M19-0505

American Nurses Association/Centers for Disease Control and Prevention Workgroup. (2017). Nurses’ Role in Hospital Antibiotic Stewardship Practices. Retrieved from https://www.cdc.gov/antibiotic-use/healthcare/pdfs/ANA-CDC-whitepaper.pdf