Please cretique my URI treatment plan

Trauma Columnist · Oct 9, 2011

Wow - I will be honest I work with renal pts and I give out tons and tons of antibiotics (I should buy stock in the company that makes Vanco/Gent/Tobra - lol).

So, I think thats comprehensive. However, why would you give a script for antibiotics when you don't want the pt to take them unless certain conditions are met?

Not criticizing, just asking as I am not used to primary care.

Also, I do question the chest pain part - it seems like the pt might need a CXR at this point versus antibiotics. I would maybe add that if you do develop CP with inspiration, come on back or go to the ER. You are leaving a lot up to the pts.

Spacklehead, MSN, NP · Oct 9, 2011

The part about pain in the cheeks, upper teeth, forehead would not be a good enough indictator "for me" to prescribe abx. since most of my patients with a cold come in after only 2 days of symptoms c/o of this. I don't think a lot of patients quite get that with a cold, you WILL have pressure/discomfort in the sinuses along with headaches at times. It's just the nature of the virus. Also, having a patient who is an asthmatic, smoker or diabetic would not prompt me to presribe abx "just because."

Unfortunately, your medical director is one of the reasons many patients think their colds are true "sinus infections" and need "that Z-pak" after 2-3 days of symptoms and become very annoyed when I won't give it to them if I don't see signs/symptoms of a true bacterial infection.

Honestly, I'd consider handing patients your list with #1-7 (with some modification) and then also another sheet explaining antibiotic overuse and how they will do nothing for a cold. I would also instruct them with which symptoms and at what point they should return to your clinic for further treatment/follow-up.

core0 · Oct 9, 2011

dear colleagues,
my name is paul mercier. i am a fnp with nine years experience working in ers and urgent care facilities.
i am writing to request a peer critique of a treatment plan that i have been personally using as well as offering to my patients who are diagnosed with an uri or viral syndrome.
i have recently been admonished by my medical director because of one complaint by a patient who simply wanted antibiotics. please note that item #8 of my treatment plan discusses when to take the antibiotics. i send each patient home with a prescription of an antibiotic because my medical director insists. he has two reasons for giving all patients antibiotics, #1 all patients presenting with signs, symptoms and a history consistent with a viral illness have a secondary bacterial infection (i can find no research supporting this) and #2 all patients expect an antibiotic and if they don't receive one they will not return to the clinic because they are unsatisfied.
please share your thoughts.
here is the plan:
1. at the onset of symptoms, irrigate your sinuses with an over-the-counter neti pot upon waking and before going to bed, and use zicam cold remedy oral mist according to package instructions.
i would take a look at zicam and fda action. there is a decent cochrane report. zinc shows some effectiveness but the dose is unclear. i would hesitate to recommend something like this without clear evidence.
2. drink plenty of clear liquids.
3. alternate tylenol and motrin every 3 hours for fever and or body aches.
max recommended dose of tylenol is now 3 grams. would emphasize this.
4. treat runny nose or post nasal drip with claritin or benadryl.
5. take 3-4 grams of vitamin c daily.
look at g6pd deficiency before recommending this.
6. treat sinus &/or chest congestion with mucinex or guiafenesin.
7. treat sinus congestion by:
* wearing a breathe right nasal strip while sleeping.
* elevating the head of your bed to promote drainage.
* taking pseudoephedrine according to package instructions, (avoid if you have, or are being treated for high blood pressure). pseudoephedrine is kept behind the counter and you must ask the pharmacist for it.
* using afrin nasal spray every 12 hours. stop using afrin after three days!
8. take the antibiotic under the following circumstances:
* if you develop a fever of 101 degrees that will not come down after taking tylenol and motrin.
* if you develop pain in your chest or back when breathing.
* if you develop pain in your upper teeth, cheeks or forehead.
* if you were prescribed a steroid (medrol dosepak or prednisone).
* if you are diabetic, asthmatic or a heavy smoker.
if your symptoms are not better after 12 days.

agree with others. if they meet the above criteria they probably should be reassessed. the medical director is simply taking the easy way out and giving everyone antibiotics thereby increasing resistance. pts with uris should be educated and brought back if the symptoms are not improving.

mammac5 · Oct 9, 2011

I hate that your medical director operates in a non-evidenced based way, but you have to determine how YOU are going to practice. No one can force you to write any medication - including ABX - that you feel are unnecessary or possibly harmful. Unfortunately in your situation, standing up for your choice to practice in a responsible way may mean looking for another job. I don't mean to be snarky but the truth is that as long as "midlevel" providers allow physicians to dictate how we will practice based only on customer satisfaction, we will never be seen as having the smarts and the clinical acumen to make good decisions based on science and our knowledge of our patients.

I was taught (by a great PA who precepted me on one of my clinical rotations) never to tell a patient that he/she has, "just a virus" because they feel like crap and they don't want to hear "just" as if it's not important. Instead, I developed a little script that goes like this:

The bad news is you have a viral infection, which is going to make you feel really lousy for the next week or so. There are lots of things I can recommend to help you feel better while your own immune system gets rid of the virus. (Then make recommendations based on each patient's history and symptoms).

The good news is you don't need an antibiotic which could only make you feel worse at this point by giving you diarrhea, abdominal cramps, a lady partsl yeast infection, rash or even a life-threatening allergic reaction. If these things occur (fill in the blanks for signs of secondary bacterial infection) please call the office and we'll talk about what's going on.

PMercier · Oct 10, 2011

To answer the questions posed by TraumaRUs:

"why would you give a script for antibiotics when you don't want the pt to take them unless certain conditions are met?"

My medical director insists that an antibiotic Rx is given to the patient. I go to great detail explaining the difference between viral and bacterial illnesses. If a secondary bacterial infection develops in the form of a sinus infection or pneumonia I want the patient to have the antibiotic and hopefully avoid an expensive trip to the ER. Each patient is advised to follow up with their PCP, the physician we refer them to if they do not have a PCP or to return to our facility if they start the antibiotics according to my treatment plan.

nomadcrna, DNP, CRNA, NP · Oct 10, 2011

UpToDate is your friend. Practice evidenced based medicine and tell your "director" to show you the evidence otherwise just say no.

I give out very few antibiotics. There is absolutely no reason to give an antibiotic for a viral URI, which the vast majority are.

You are responsible for your scripts (and liable) not your director.

Thank god I live in an independent practice state. That would drive me crazy