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Infection

An audit of trust guidelines compliance on management of lower urinary tract infections

The work described here was presented at the UKCPA Virtual Conference Poster Day 2021

Antimicrobial resistance is the biggest threat to modern day healthcare, potentially sending us back to a pre-antibiotic era. Since 2015 there has been a one-third increase in antibiotic-resistant blood stream infections, with E. coli being the most common. 

Urinary tract infections (UTIs) are the leading cause of E. coli and gram-negative infections, and as such have been included in NHS England’s Commissioning for Quality and Innovations (CQUIN) scheme. To aid this, Public Health England (PHE) have also issued guidance on diagnosing UTIs. While the 2019/20 CQUIN focused on diagnosis and treatment of UTI in over 65-year olds, this audit assessed the compliance to NHS treatment pathway of all adults aged over 16 and under 65 years old that have not previously been audited.

The objective of the audit was to assess appropriate diagnosis and treatment of UTIs in 16 to 64-year-olds at the Trust, with the expectation of 80 percent compliance in the following standards:

  • Patients having symptoms of a UTI documented in their clinical notes
  • The results of a urine dipstick test documented in their clinical notes
  • Have had a midstream sample of urine (MSU) sent
  • If appropriate, an antibiotic prescribed that complies with NICE/trust guidelines.

All data were collected between September and October 2020. For this prospective audit patients with a documented indication of lower UTI and aged between 16 and 64 were identified using a daily antibiotic list, collated from the electronic prescribing system. Electronic medical notes were used to review symptoms, results (urine dipstick and sample) and drugs prescribed. Paper notes were checked if information was not available electronically. Patients who were pregnant, or had complicated, upper or catheter associated UTIs and urosepsis were excluded. 

Meeting all the criteria is not a necessity to be deemed suitable for antibiotics. Taking this into consideration, the proportion appropriately prescribed antibiotics was 46 percent. 

Data were collected from 28 patients (64 percent female and 36 percent male). Sixty-one percent of patients had documented signs of a UTI. Sixty-eight percent had a documented urine dipstick result and 86 percent had an MSU sample sent.  The vast majority (89 percent) of patients were prescribed antibiotics in line with trust guidelines. Over a third (39 percent) of patients had met all of the criteria outlined above. 

Despite appropriate antibiotics being prescribed in the majority of cases, overall the number of patients meeting all the criteria was fairly low. However, meeting all the criteria is not a necessity to be deemed suitable for antibiotics as set out in the PHE UTI guidance. For example, patients presenting with two or more symptoms of a UTI do not need a dipstick. Taking this into consideration, the proportion appropriately prescribed antibiotics was 46 percent. 

Improvements can be made through education and awareness of how and when to treat. Limitations of this audit include a small sample size, limited access to paper notes and assumptions over symptoms. Future work should include the reliability of dipstick tests and optimising the approach to UTI diagnosis.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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