CITATION: Kunin CM. 1995. Ask the expert.
APUA Newsletter 13(3):5.


Letters to Dr. Kunin regarding telephone prescribing followed by his reply



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Ask the Expert

Should physicians prescribe antibiotics over the telephone?
Calvin M. Kunin, MD
Internal Medicine, The Ohio State University, Columbus, Ohio, USA


It is not uncommon for physicians to be called by a patient or a member of his or her family to prescribe an antibiotic over the telephone. Physicians who accede to these requests, without seeing the person, do so at considerable peril to both themselves and their patients. The physician immediately becomes liable for potential misdiagnoses and adverse reactions. It is virtually impossible to muster a legal defense if something goes wrong. What could be more foolish? A few example cases may be helpful.

Failure to examine the patient. A 36-year-old man with a recurrent sore throat called a clinic to make an appointment to see a physician. Instead of seeing the patient, the physician prescribed a new macrolide antibiotic over the telephone. The patient was seen the next day by another physician who noted several large aphthous ulcers on the posterior pharynx. There was no evidence of a bacterial infection. The antibiotic was stopped and a topical anesthetic was prescribed.

Failure to recognize drug interactions. A 24-year-old man with a prosthetic heart valve developed a productive cough and fever. He had been on long-term warfarin therapy. The prothrombin time was frequently monitored and maintained at therapeutic levels. His physician was not available and his partner was notified. The partner had never seen the patient, but prescribed doxycycline over the telephone for the presumed bacterial respiratory infection. Several days later the man suffered a massive intracerebral bleed and was found to have a prothrombin time of more than 60 seconds. The package insert for doxycycline states under Drug Interactions: "Because tetracyclines have been shown to depress plasma prothrombin activity, patients who are on anticoagulant therapy may require downward adjustment of their anticoagulant dosage."

Failure to do a dip-stick urinalysis.  A 52-year-old woman developed a urinary tract infection and was treated with a long-acting nitrofurantoin preparation. She responded promptly to the medication, but about a week later noted some burning on urination. The office nurse renewed the prescription by telephone. Shortly after taking the next dose the patient became faint, confused and febrile. The urine was sterile and did not contain any pus cells. Not all burning on urination is due to urinary infection.

Failure to recognize the compulsive antibiotic user.  A 48-year-old woman had received repeated courses of antibiotics because of episodes of diarrhea. She ultimately underwent procto-sigmoidoscopy and was found to have pseudomembranous ulcerative colitis. Clostridium difficile toxin was present in her stool. She was warned not to take antibiotics without good reason. Nevertheless, in planning a trip to Mexico she called the offices of several physicians to obtain antibiotics for herself and her family in the hope of preventing diarrhea. At least one office prescribed tetracycline over the telephone. The pharmacist noted that the woman often purchases antibiotics using prescriptions from many different physicians.

Suggestions for dealing with telephone requests:

  • Instruct your staff never to prescribe or renew prescriptions for antibiotics over the telephone without your express permission and only after you have reviewed the patientís record.
  • Never prescribe antibiotics over the telephone for a person you have not seen for the current illness.
  • Never change one antibiotic to another over the telephone without first seeing the patient.
  • Ask at least one member of the family to come to see you if they plan to travel abroad. You need to discuss immunizations, oral replacement therapy (ORT) for diarrhea and other hygienic practices as well as to consider the use of prophylactic antibiotics.
  • Anticipate that patients with recurring urinary tract infections may develop an acute episode at any time. The patient may be traveling or you may not be immediately available to help out. Provide the patient with a prescription to purchase a sufficient amount of your drug of choice to be available when needed. Similar anticipatory measures can be used for patients with other recurrent infections.

There might be times when prescribing an antibiotic over the telephone is justified, but these should be rare indeed.

 

ALLIANCE FOR THE PRUDENT USE OF ANTIBIOTICS © 1999

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