The Antimicrobial resistance CQUIN 2019/20 Part CCG1a assesses the appropriate diagnosis and management of lower urinary tract infection (UTI) in older people. This quality improvement initiative is underpinned by recent NICE guidance on the management of UTI as well as Public Health England’s diagnostic guidance.
Building on the successes of previous antimicrobial focused CQUINs, this year the objective is for Acute NHS Trusts to submit patient-level data to identify whether:
- The Public Health England (PHE) diagnosis guideline from primary care was followed to diagnose the UTI
- A urine dip stick was notused to diagnose the lower UTI
- A urine culture was sent to microbiology in line with PHE and NICE guidance
- Antimicrobial therapy was prescribed in line with NICE lower UTI guidance, local empirical guidelines or recent positive microbiology results.
The London Antimicrobial Stewardship Pharmacist Group (L-AMS group) reviewed the new national CQUIN and identified three key areas of potential ambiguity or interpretation of the data collection based on early work completed across London’s Acute Trusts.
Urine dipstick to diagnose a lower UTI
It is widely agreed that use of a urine dipstick alone for diagnosing UTI in patients of more than 65 years old is not advisable. The L-AMS group interpret the question “Was a urine dip stick used to diagnose a lower UTI?” to mean that any UTI diagnosis based on the outcome of a urine dipstick should be defined as non-compliance with the CQUIN target.
If a urine dipstick had been performed but had not informed the diagnosis of the UTI, then this should not result in failure of compliance for this specific component of the CQUIN target. Cases where urine dipsticks are performed for other indications in line with best practice, such as acute kidney injuryor urinary incontinence and pelvic organ prolapse in women, should not be penalised. This interpretation has been agreed with NHS England CQUIN lead, Elizabeth Beech (personal communication, July 2019).
Urine culturesare advised for all male, pregnant or catheterised patients presenting with signs and symptoms of a UTI
The guidelines do not advise on when to send cultures from non-pregnant women. The PHE diagnostic toolkit provides more detail, with recommendations to “send urine culture if feasiblebefore starting antibiotics”.
The London Antimicrobial Stewardship Pharmacist Group identified three key areas of potential ambiguity
In acute outpatient settings, including Accident & Emergency or Urgent Care Centres (UCC), a transient patient population make continuity of care difficult. Testing urine and following up sensitivities may not be feasible in these settings and thus is not universally requested in A&E or UCCs within London.
For patients admitted to hospital urine cultures is strongly recommended, as the carriage of resistant organisms is expected to be greater than in the community setting. The continuity of care of these patients allows for empiric treatment to be tailored following culture.
The L-AMS group agrees that all patients admitted to hospital with lower UTI or any patients presenting with hospital acquired UTI must have a urine culture sent pre-treatment. Routine culture for outpatient uncomplicated UTI may not be feasible but is desirable, as outlined by NHS England CQUIN guidance. Novel methods to enable busy outpatients to handover the urine culture results to the patient’s GP are needed.
The CQUIN advises that 100 patients with an ICD-10 coded diagnosis of N39.0 (Urinary Tract Infection) and N30.0. (Cystitis) (ED code 27. SNOMED code 68226007) are included in the quarterly audit. Patients with complicated UTI or symptoms of systemic infection, including temperature over 37.9°C or 36°C or below, should be excluded.
The number of admitted patients with a primary diagnosis of uncomplicated lower UTI that warrant a hospital admission is expected to be low; these patients are commonly treated in primary care. Where Trusts have access to electronic prescribing or medical records that would identify inpatients with lower UTI symptoms, these may be a more timely and sensitive source of patient inclusion. The NHS England team confirm alternate methods of patient identification if retrospective analysis is still performed (personal communication, July 2019). Point prevalence auditing or random sampling may also be possible to identify patients on treatment.
The L-AMS group welcomes this national CQUIN and expects the auditing of local practice and benchmarking against peers will improve the diagnosis and treatment of uncomplicated lower UTI in older patients. However, the group has identified some subjectivity in the audit standards and has discussed standardisation of data collected within London. We wish to share this collaborative work with the NHS England team and highlight some of the logistical challenges in collecting this data. We hope that the practical approach agreed by the London hospitals accurately incorporates the desired quality improvements in the management and treatment of UTI whilst meeting the CQUIN objectives.
The authors would like to acknowledge Caoimhe Nic Fhogartaigh, consultant in Infectious Diseases & Microbiology and Antimicrobial Stewardship lead at Barts Health NHS Trust, as a contributor to this article.
The opinions expressed in this article are those of the authors. 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:
All authors declare: 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.