Antibiotic Stewardship for FNP Boards: When to Prescribe and When to Wait

Pharmacology · 9 min read · April 14, 2026

Why Antibiotic Stewardship Is Board-Tested

Inappropriate antibiotic prescribing is one of the most significant public health problems in medicine. The FNP boards test antibiotic stewardship because it's a core competency of primary care practice.

The boards will test you on two things: knowing when antibiotics are indicated, and knowing which antibiotic to choose.

Conditions That Do NOT Require Antibiotics

Viral upper respiratory infections: The common cold is caused by rhinovirus. Antibiotics do nothing. Treat with supportive care.

Viral pharyngitis: Most pharyngitis is viral. Only treat with antibiotics if Strep test is positive.

Acute bronchitis: Almost always viral. Antibiotics are not indicated. Treat with supportive care, cough suppressants.

Viral sinusitis: Most acute sinusitis is viral. Reserve antibiotics for bacterial sinusitis (symptoms >10 days, severe symptoms, or worsening after initial improvement).

Otitis media with effusion: Fluid in the middle ear without infection. No antibiotics needed.

Conditions That DO Require Antibiotics

Strep pharyngitis: Positive rapid strep test or culture. First-line: Amoxicillin x10 days (or penicillin). Azithromycin if penicillin allergic.

Acute bacterial sinusitis: Amoxicillin-clavulanate first-line. Doxycycline or respiratory fluoroquinolone if penicillin allergic.

Acute otitis media (AOM): Amoxicillin first-line. Amoxicillin-clavulanate if treatment failure or recent antibiotic use.

Community-acquired pneumonia: See respiratory chapter for treatment algorithm.

UTI: See renal chapter for treatment algorithm.

Skin and soft tissue infections: Cephalexin for non-purulent cellulitis; TMP-SMX or doxycycline for purulent infections (MRSA coverage).

High-Yield Antibiotic Classes

Penicillins (amoxicillin, ampicillin): Gram-positive coverage; amoxicillin-clavulanate adds beta-lactamase coverage

Cephalosporins: Broad spectrum; first-generation (cephalexin) for skin; third-generation (ceftriaxone) for serious infections

Macrolides (azithromycin, clarithromycin): Atypical organisms, respiratory infections; increasing resistance

Fluoroquinolones (ciprofloxacin, levofloxacin): Broad spectrum; UTI, respiratory; avoid in children, pregnancy, tendon rupture risk

Tetracyclines (doxycycline): Atypicals, STIs, Lyme disease; avoid in pregnancy and children <8

TMP-SMX: UTI, MRSA skin infections; avoid in first trimester and near term

Metronidazole: Anaerobes, BV, C. diff, H. pylori; avoid alcohol (disulfiram reaction)

The Board Decision Tree

When a board question asks about antibiotic choice:

Is an antibiotic indicated? (Bacterial vs. viral)
What organism is most likely?
What is the first-line antibiotic for that organism/condition?
Are there any patient factors that change the choice? (Allergies, pregnancy, renal function, local resistance patterns)