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 Dr. 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.  

A 34-year-old woman presents with an uncomplicated UTI. Her last menstrual period ended approximately five days ago and she has a history of bilateral tubal ligation that was performed about five years ago. She's otherwise healthy, has not received a systemic antimicrobial in the past year, denies drug allergies, and is not taking any medications. Per local antibiogram, E. coli resistance rate to trimethoprim sulfamethoxazole (TMP/SMX) is about 25%. Which of the following represents the best choice of therapy?  

A. Prescribe a course of 3-day oral trimethoprim-sulfamethoxazole (Bactrim).
B. Order a single dose of IM ceftriaxone, trade name Rocephin.
C. Prescribe a 5-day course of oral nitrofurantoin, also known as Macrobid.
D. Advise that a 1-week course of oral ciprofloxacin (Cipro) therapy is needed 

 Where do you start? 

First, determine what kind of question this is. Given that we're informed the patient has an uncomplicated UTI and we're now directed to treat, this is a plan/intervention question. The diagnosis of uncomplicated UTI sometimes referred to as uncomplicated lower UTI, implies an inflammation of the bladder, urethra, and associated structures by select pathogens. The upper urinary tract, including the kidneys, are not involved. And remember an upper urinary tract infection that would include the kidneys would be a pyelonephritis. The gram-negative organism E. coli, gram negative rod, accounts for about 80 to 90% of all UTIs regardless of age or birth or gender assignment. Antimicrobial therapy is first-line treatment. 

 Next, we want to consider the information that's been provided about this patient. 

First this is a younger adult without chronic health problems and has not recently taken a systemic antimicrobial. Noting this is helpful as it limits the risk that the UTI might be more problematic to treat because recent systemic antimicrobial therapy increases the risk of infection with a resistant organism. Having had a bilateral tubal ligation, consider the pregnancy risk is virtually eliminated. Tubal ligation has a failure rate of less than 0.1%. And she is without allergies. 

These two pieces of information are helpful because both pregnancy and drug allergy can potentially limit therapeutic choices. 

Let's take a look then at the options we have been given. 

 Would the best choice be to A. prescribe a three-day course of oral trimethoprim sulfamethoxazole? Well, we're informed that the local E.coli resistance rate to this antibiotic is about 25%. 

Evidence-based practice dictates that trimethoprim sulfamethoxazole use is only acceptable in UTI when the rates of resistance are less than 20%. 

I will say there is virtually no place in the United States currently where you are going to find that the trimethoprim sulfamethoxazole resistance rates are less than 20% when you're looking at E.coli.  

So in other words, we're not going to use that antibiotic because of the risk of resistant pathogens. 

If you're asking yourself, where do I get my local antibio gram, you can either get it from your local department of Public Health, from your pharmacy therapeutics committee (if you’re part of a larger healthcare system), or from your local microbiology lab (in other words, the lab that you send out your cultures to). 

Would it be option B? Order a single dose of IM ceftriaxone? 

Well, this might actually work, oral therapies are preferred over injectable therapies, particularly with a person who is at baseline well, is going to be treated as an outpatient. Pharm 101 dictates the following: do not inject what you can give PO. This is also an example of an answer where if you've got your RN headspace on instead of your NP headspace on, you might think to yourself, Well, I've seen ceftriaxone in the inpatient setting used a lot to treat UTIs. And in that case, you'd be 100% correct; but, we're talking about outpatient practice here, and that's different than what we do in the inpatient setting. 

Next option, option C would be prescribe a five day course of oral nitrofurantoin or Macrobid. This is actually the correct answer. It's the right drug and the right length of therapy with very high rates of UTI resolution and very low rates of resistance. Option D advises that a one week course of oral ciprofloxacin therapy is needed. That's not correct, and the reason for that is rising rates of resistance dictate that ciprofloxacin, a fluoroquinolone, is no longer considered to be first-line therapy in uncomplicated lower UTI. 

 Key takeaway: in order to prescribe an antimicrobial safely and effectively — knowing the possible causative organisms, the meds that are most effective against at work in is or organisms, and patient factors. Coupling that together with evidence-based practice is key.  

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.