Appropriate management of urinary tract infections in older patients

As one of the most common infections at community level, the implications of a urinary tract infection (UTI) are well known to pharmacists across both primary and secondary care. Older people are particularly at risk of a UTI, with the presence of asymptomatic bacteriuria historically complicating diagnosis within community settings​[1]​.

Owing to the real and large-scale implications of antimicrobial resistance, the safeguarding of antibiotic use is of paramount importance. As trimethoprim resistance is common and widespread, empirical use is not recommended by the South-Central Antimicrobial Network (SCAN)​[2]​. Despite this, in June 2021, trimethoprim prescribing across the Hampshire, Southampton and Isle of Wight Integrated Care Board (ICB) remained at 4% above the national median​[3]​. 

UTI prescribing practices for non-catheterised patients aged over 65 years were analysed at Ringwood Medical Centre, Hampshire. Prior to analysis, trimethoprim prescribing was 10% above the national average​[4]​. Antibiotic prescriptions were evaluated in line with both local SCAN and National Institute for Health and Care Excellence (NICE) guidelines​[2,5]​. Audit standards aimed to minimise the inappropriate use of trimethoprim and ensure the appropriate documentation of clinical signs, symptoms, and samples (midstream specimen of urine [MSC]) to aid correct diagnosis.

Eligible samples, defined as patients aged over 65 years diagnosed and treated for a UTI with an indicated antibiotic, were identified through a SystmOne (The Phoenix Partnership) data search across two three-month periods between 2021 (June–August 2021) and 2022 (December–February). Patient data was randomly selected from respective samples of 155 (June-August 2021) and 112 (December-February 2022). Across both time periods, 15 patients were sampled (one patient per 1,000 registered at the practice). The Royal College of General Practitioners (RCGP) TARGET UTI audit toolkit was used to guide data collection and analysis​[6]​. 

The initial search (June–August 2021) found that only 27% of patients (n=4) had been prescribed the correct antibiotic at the right strength, dose, frequency and duration. This was mostly owing to one of two factors. First, trimethoprim was being used for empirical therapy in the absence of an MSU or microbiology guidance. Second, where nitrofurantoin was used correctly, female course lengths were commonly prescribed at five to seven days in contrast to the three-day treatment duration recommended by both SCAN and NICE​[2,5]​. Findings were written up and verbally presented to the prescribing lead at Ringwood Medical Centre with an emphasis on improvement in these two areas. Following this, the presentation was communicated electronically to all prescribers at the practice. Healthcare professionals were signposted to current UTI prescribing guidelines and were encouraged to use the Arden’s UTI template (built into SystmOne). Using the template would help to ensure that each consultation was accompanied by the clear documentation of clinical signs, symptoms, red flag criteria and differential diagnosis.

Time was allowed for prescribing change to take place before data collection and analysis were repeated. Following the provision of simple and informative feedback, a 49% increase (n=7) in correct prescribing practices was observed between December and February. Overall, 73% (n=11) of antibiotics had been prescribed appropriately. Nitrofurantoin course lengths for females had been standardised at three days and no instances of empirical trimethoprim prescribing were identified, as alternatives had been appropriately prescribed. Trimethoprim prescribing at the practice had declined to 7% below the national median​[4]​. The exclusion of red flag criteria or differential diagnosis remained poorly documented, forming the basis of further recommendations. 

A significant improvement in antibiotic use was observed between the two time periods measured; however, there remains a need for further improvement. In particular, the clear documentation of referral criteria and differential diagnosis, both of which have a vital role in safeguarding the management of urinary symptoms in those aged over 65 years. The audit was to be reviewed on an annual basis and recent prescribing data remains positive. In September 2022, trimethoprim prescribing at Ringwood Medical Centre was sustained at 6% below the national average​[4]​.

The results highlighted the need to ensure prescribers are not only aware of current guidance, but actively implement it within day-to-day practice. Recommendations were straightforward, effective and easily reproducible. The audit was later extended to the other practices across the Avon Valley Primary Care Network. Nitrofurantoin course length and empirical trimethoprim use were identified as universal areas for improvement, in conjunction with the poor documentation of red flag criteria. The improvement in trimethoprim prescribing at Ringwood Medical Centre has been widely shared across the ICB and has since inspired further evaluation of trimethoprim use in general practice across Hampshire, Southampton and the Isle of Wight.

Amy Dalziel, resident pharmacist at Oxford University Hospitals NHS Foundation Trust on behalf of Hampshire, Southampton and Isle of Wight Integrated Care Board.