Why has Public Health England updated this guidance?

We continue to see rises in blood stream infections, particularly particularly Escherichia coli bloodstream infections, which increased by 22% between 2013 and 2017. Without intervention this could rise to 50,663 cases by 2021 with 6,554 fatalities according to recent estimates.[1] The Department of Health and Social Care (DHSC) aims to halve Gram Negative Bloodstream Infections by 2020. The NHS Quality Premium (QP) for 2017/2019 has set CCGs targets of reducing E.coli bacteraemia and inappropriate antibiotic prescribing.

Surveillance shows that previous UTIs, urinary catheterisation, hospitalisation, antibiotics in the previous month and older age are key risk factors for these infections. To help address the DHSC targets and the QP, we have updated primary care diagnostic guides and resources for urinary tract infection (UTI).[2]

The resources include a new diagnostic flowchart and a patient leaflet to facilitate the management of suspected UTIs in the older frail population. They have been developed with general practice staff, care home staff, residents and relatives, stakeholders and professional societies.

What are the most important changes from existing guidelines?

The Public Health England (PHE) UTI diagnostic flowchart provides more detailed advice on how to undertake the full clinical assessment recommended in the 2015 NICE quality standard on diagnosis of infections in the elderly. This is important when managing this group of patients, particularly those in care homes. It includes some key recommendations on recognising sepsis, increasing understanding about asymptomatic bacteriuria and reducing urine dipstick use, to improve antibiotic use in frail older people.

Why do you advise against any use of dipsticks in the elderly?

Asymptomatic bacteriuria is very common in the elderly, and therefore even if an older person has a positive dipstick test, the bacteriuria may not be responsible for the symptoms.

Relying on urine dipstick results means that many elderly people may be given antibiotics unnecessarily. We know that increased use of antibiotics is associated with increased resistance, and so this diagnostic flowchart and accompanying leaflet alongside care home ‘to dip or not to dip’ resources will help to guide antibiotic prescribing and ultimately improve use.

What if GPs are asked for antibiotics for an elderly patient, based on a positive dipstick result?

We suggest that GPs explain that urine dipstick tests should not be used in this age group as they are not accurate, and produce many false positives. We advise that GPs use the flowchart as a guide for enquiring about a patient’s symptoms, first excluding pyelonephritis and sepsis which require different management and possible hospital admission.

If an older person has an abnormal temperature and new onset dysuria or two other symptoms or signs of UTI, then a UTI is likely (unless symptoms are very mild) and an antibiotic is warranted in line with local guidance.

For patients in whom care home staff phone to say a dipstick is positive but they are asymptomatic, we recommend that clinicians advise against an antibiotic. A UTI is less likely when patients present with confusion alone without an abnormal temperature, or with vaginal discharge or atrophy.

We hope that the flow chart will be laminated and displayed in GP practices to guide the diagnostic and prescribing process.

What other recommendations should change GPs’ practice?

Another aim of the flowchart is to increase the recognition of sepsis or upper UTI (pyelonephritis), so leading to more appropriate antibiotic choice to treat these effectively with the right antibiotic in the first instance.

The guidance also advises a urine culture in all patients over 65 years who are given an antibiotic for UTI. This is because antibiotic resistance is highest in the elderly, and therefore clinicians can check that the prescription is correct or change to another agent if needed. This approach of ‘starting smart, then focusing’ will help reduce E.coli bacteraemia and antibiotic resistance.

In addition, healthcare staff are asked to consider other causes of confusion in the older frail patients, using the very memorable acronym PINCH ME (Pain, other Infection, poor Nutrition, Constipation, poor Hydration, other Medication, Environment change).

These resources support primary and social care staff using a diagnostic algorithm/guide to improve diagnosis of suspected UTIs, fever and other non-specific signs of infection, and consider pyelonephritis and sepsis.

A complementary UTI information leaflet aims to increase understanding of prevention of UTIs, self-care and what symptoms would warrant seeking advice, by frail older patients living in social care or the community, their carers and health professionals.

What about younger patient groups with suspected UTI?

The diagnostic flow chart for younger adults has also been updated following a large Health Technology Assessment (HTA) study in the UK and several systematic reviews. This suggests that other causes of urinary symptoms should always be excluded when a patient presents, such as vaginal infections, urethral inflammation post sexual intercourse and sexually transmitted Infections. Atrophic vaginitis can also cause urinary symptoms. Again, as in older frail adults, PHE also advises that pyelonephritis and sepsis is excluded.

This guidance will lead to some change in practice, as the new guidance for acute uncomplicated UTI advises clinicians to ask about the three key diagnostic symptoms/signs suggesting UTI which were shown to help differentiate those patients with proven UTI in the HTA study. These are dysuria, new nocturia and cloudy urine; if the patient has two or three of these symptoms, which will be about 70% of patients, a UTI is likely and empirical antibiotics should be prescribed. If the patient has only one of these or none but other symptoms are severe, a urine dipstick to guide management is suggested.

What do you hope the revised guidance will achieve?

The resources will complement national implementation of ‘To Dip Or Not To Dip’, a patient centred approach in care homes, and the NICE UTI antibiotic guidance. As a result we hope that use of antibiotics in patients presenting with suspected UTI in all ages will be improved, leading to decreased overall antibiotic use, and more appropriate antibiotics for patients with suspected pyelonephritis and sepsis. Combined with safety netting and use of the PHE TARGET leaflets, this should help to reduce E.coli bacteraemia and hospital admissions, and in the longer term reduce the increase in antibiotic resistance.

We are currently seeking views on the draft updated resources.[3] The consultation closes on 30 May 2018

Professor Cliodna McNulty is head of the PHE Primary Care Unit  

References

1. Bhattacharya, A et al. Estimating the incidence and 30-day all-cause mortality rate of Escherichia coli bacteraemia in England by 2020/21. J Hosp Infect 2018; 98: 228–231 

2. Public Health England. Diagnosis of urinary tract infections: quick reference guide