Antimicrobial Therapy Request

A nurse practitioner receives a message from a neighbor, a 35-year-old woman who is asking for a prescription to treat a “urine infection”. The neighbor states she's had this condition occur in the past and does quite well if she gets on an antimicrobial quickly. The neighbor also mentions that she's going out of town on a business trip the next day and is unable to contact her personal healthcare provider nor get to urgent care. 

The NP considers the following in prescribing a medication to her neighbor.  

A. Given this is a request for a prescription that is not a controlled substance, the NP can provide the prescription as long as the patient can advise on what antimicrobials she has taken in the past. 

B. Providing this prescription would be a violation of federal law. 

C. In suspected UTI, an antimicrobial prescription should not be initiated until urine culture results are available.  

D. Since the NP does not have a patient provider relationship established with her neighbor, the request for an antimicrobial should be declined. 

---

YouTube: https://www.youtube.com/watch?v=G1IN08Ioh74&list=PLf0PFEPBXfq592b5zCthlxSNIEM-H-EtD&index=121

Visit fhea.com to learn more!

Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A nurse practitioner receives a message from a neighbor, a 35-year-old woman who is asking for a prescription to treat a “urine infection.” The neighbor states that she's had this condition in the past and does quite well if she gets on an antimicrobial quickly. The neighbor also mentions that she's going out of town on a business trip the next day and is unable to contact her personal health care provider, nor get to urgent care. 

The NP considers the following in prescribing new medication to her neighbor:  

A: Given that this is a request for a prescription that's not a controlled substance, the NP can provide the prescription as long as a patient can advise on what antimicrobial she's taken in the past.  

B: Providing this prescription would be a violation of federal law.  

C: In a suspected UTI an antimicrobial prescription should not be initiated until urine culture results are available.  

D: Since the NP does not have a patient-provider relationship established with her neighbor, the request for an antimicrobial should be declined. 

And the correct answer here is D.: Since the NP does not have a patient provider relationship established with her neighbor, the request for an antimicrobial should be declined. 

Where should you start with this question? First, determine what kind of a question it is. This would be one that would come under the category of maybe plan, because obviously it's talking about treating a UTI and it's talking about a specific intervention or perhaps professional issues. Long and short-it's a type of a question that could be fair game on any of the NP boards. 

A little bit of background information here. As you transition into your NP role, a scenario like this will come up sooner or later. 

And as NP practice broadens and more people are aware of what we can do as clinicians, which candidly, is something that's long overdue. Often a neighbor, a friend, a coworker, sometimes your relative that you haven't heard from in 10 years will suddenly contact you and ask for a med refill or a new prescription. 

I can remember when I was first a nurse practitioner many years ago, having a person who worked in the same building, but not for the same company as I did, who I hardly knew she was literally somebody I would say hello to in the hallway. I'm not even sure if I knew what her name was or what her role was, but I recognized her as working the same building with me, very, very casually stopping me in the hallway and asking me to refill a prescription for her. 

And I'll have to tell you, I didn't have a good narrative, a good way of answering the question as to why I was going to say no. I did say no, but I didn't have the right narratives. And one thing I'm going to do is advise you to make sure that you have the narrative of what to say when you're asked for a prescription like this. 

I'll share with you a little later in this podcast what I say to people. But let's take a look at some basic prescribing principles. Envision yourself in the exam room seeing a person with UTI-like symptoms, like your neighbor. You would have performed a thorough patient assessment, get the needed diagnostics, ensure there were no drug-drug interactions or drug allergies, consider comorbidities, likelihood of pregnancy or not, a number of other factors.  

And then, and only then, would you have gone ahead and prescribed the medication. Correct. And as important as your clinical judgment, you would have documented the entire process in the patient's record. This would allow the patient to receive care in your system, even in your absence, as your colleagues would be able to check your clinical note, see if there were any red flags, and then better assess the patient, particularly if there was treatment failure. 

When you prescribe any medication to a patient where you do not have an ongoing patient-provider relationship, you have pretty much bypassed all those and other steps in the clinical process. Indeed, I find one of the ways I quickly get around requests for medications by people who are not my patient, I say something to the effect of, “I don't have access to your patient records. 

I don't have the ability to get tests. I would need to make an informed diagnosis. I cannot document our interaction. And as a result, I'm unable to prescribe a medication for you.” Full stop. And at one time, I'll tell you, I would have said, “Oh, I'm really sorry. No, I can't help you out.” And then I would have elaborated on why I- 

I know this sounds harsh. I don't apologize for not being able to help someone out. I don't, because it's an intrusion on my professionalism to say, “Oh, you know, we walked by one another once in a while in the hallway. Will you refill my high blood pressure medicines or whatever it is?” Because if I say< “I'm sorry, I can't help you out.” 

That, to me, implies that I want to help the person out, but I can't. The reality is, I don't want to help the person out. Go back to your own provider. But I find virtually when I say the reasons why I can't, people will kind of 99 times out of 100 nod their head and go, “Oh, okay, I understand.” 

So that's what you want to do is develop that narrative that works for you. With this information as background, let's revisit the question. The NP receives a message from a neighbor, a 35-year-old woman who is asking for a prescription to treat a urine infection. The neighbor states she's had this condition in the past and does quite well if she gets antimicrobial therapy quickly. 

The neighbor also mentioned she's going out of town on a business trip the next day and is unable to contact her personal health care provider nor get to urgent care. The NP considers the following and prescribing a medication to her neighbor: 

A: Given this is a request for a prescription that's not a controlled substance the NP can provide the prescription as long as the patient can advise on what antimicrobial she's taken in the past.  

Well, this looks like an answer that really sounds plausible, but it nonetheless violates what is needed for a clinician to do the thorough assessment, arrive at the appropriate diagnosis, develop a treatment plan, document all of this. Okay. And I'm not saying that if you see a person with a common problem like a UTI and they tell you they have had it in the past, what worked, what didn't work, that you wouldn't include this in the information that you use to make up a clinical decision? 

Absolutely not. Very, very important information. However, consider the differential as well. Okay. This could be an STI mimicking as a UTI. Chlamydia in particular can cause UTI-like symptoms. So can gonococcal infection. You know the list goes on and on. But nonetheless, this person is not your patient. You want to avoid this situation whether it's a controlled substance or not. 

B: Providing this prescription would be a violation of federal law. Well, there are a couple of things with this. It's not the correct answer as well. On the other hand, look at the answer. It's so succinct. Don't do it. Federal law violation. End of discussion. Very little additional information is given to you. General rule: when taking an exam, avoid the longest and the shortest answers. 

And even if the longest or the shortest answer looks like it could be the right answer, make sure you dig extra deep into why you're choosing the longest or the shortest. One other point to keep in mind: federal law dictates very little of what we can and cannot do as nurse practitioners. Our prescriptive authority comes from the state level. 

Our license to practice comes from the state level to which you might be saying to yourself, yeah, but what about my DEA number for controlled substances? You're absolutely right. That comes from the feds, but it is your state that says you're eligible to get a DEA number at the federal level. C: In suspected, UTI, antimicrobial prescriptions should not be initiated until urine culture results are available. 

Well, this is not correct. And also is an answer that might look plausible, but it has nothing to do with the point of this question, which is prescribing a medication to a person who is not your patient. Plus, on top of that, principles of empiric antimicrobial therapy-will you prescribe any antimicrobial based on a number of clinical factors, including the most likely pathogens? 

That is the rule for treating UTI. So let me kind of reframe that. You see somebody on a Monday, classic UTI-positive nitrates, positive leukocyte esterase. Let's make it an otherwise healthy 35-year-old woman. 

Like in this scenario, do you see her on Monday knowing you're not going to get back the urine culture results till probably very late on Tuesday, if not Wednesday. 

And what do you say to her? Yeah, just go home, put up with this horrible feeling where you can't leave the bathroom because you need to urinate so frequently. Plus, it hurts every time you pee. Hang around with this for the next 36 to 48 hours when I get the results back to the culture. I'll tell you what I'm going to prescribe. 

No, no, no, no, no, no. We do empiric antimicrobial therapy, which is a fancy term for best estimation of what antibiotic will work in that scenario. So, we don't wait. We don't wait a couple of days until those results are back. To do so could lead to significant clinical problems. And I'm going to expand on that. Just one more little bit. 

Many of you, as you're transitioning from your RN role, you are practicing at the RN level and in acute care setting, right? Do you see somebody intubated, ventilated, who spikes a fever, starts producing some purulent sputum and you obtain a sputum culture? Okay. Do you then see that the prescribing providers say, oh, fever spike, purulent sputum. 

Got a sputum sent to the lab on Monday. We're not going to treat that person for suspected ventilator-associated pneumonia till we get the results back in a couple of days on the culture. No, no, no, no, no, no. Empiric therapy says we start it as soon as you suspect there is an infection, because that helps mitigate the severity of the illness. 

And then once all the all the diagnostics are back, you might need to adjust the therapy. But more often than not, the person is on the right drug in the first place. Okay. D: Since the NP does not have a patient-provider relationship established with her neighbor, the request for an antimicrobial should be declined. And of course, D is the correct answer. 

Key takeaway: I advise you come up with a script that works best for you. In other words, what are you going to say to a person who's not your patient who asks for a prescription? Because it will happen sooner or later. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit fhea.com.