Antimicrobial stewardship in general practice – urinary tract infections in the over 65’s
Authors: Dalziel A , Gorman D , Corteville L 
Published: November 2022

Abstract

Introduction
Across the South Central Antimicrobial Network, trimethoprim is not recommended for empirical UTI treatment due to high levels of local resistance. Despite this, trimethoprim prescribing remains above the national median. Due to antibiotic resistance and the presence of asymptomatic bacteriuria, it is important to safeguard the management of UTI’s for older people, improving both patient outcomes and antimicrobial stewardship.

Aim
This audit aimed to reduce the inappropriate prescribing of UTI antibiotics for non-catheterised patients over the age of 65 at Ringwood Medical Centre.

Standards
100% of Trimethoprim prescriptions for a UTI will be based on cultures or microbiology advice. 100% of over 65’s treated for a UTI should have documented clinical signs and symptoms. 100% of over 65’s treated with an antibiotic for a UTI had MSU sent for cultures and sensitivities.

Methods
Data was collected and analysed in line with the RCGP TARGET UTI toolkit.1 A retrospective System One patient data search took place between 1st June – 31st August 2021. Search criteria included: ≥ 65 years, non-catheterised, coded/suspected UTI diagnosis, prescription of an indicated UTI antibiotic. Antibiotic prescribing was evaluated in comparison to local2 and national3 guidance. Ethical approval was not required. Preliminary results were presented to the prescribing lead at Ringwood Medical Centre in November 2021 and the search was repeated between 1st December – 28th February 2022. Feedback promoted the implementation of local UTI guidance and was communicated throughout the practice. 15 patients were randomly selected for analysis, sampling 1 patient per 1,000 registered at the medical centre.

Results
Between June-August, 27% of patients were prescribed the correct antibiotic at the right strength, dose, frequency and duration. This increased to 73% when the search was re-run between December-February. Analysis found duration of treatment as a significant contributor to incorrect prescribing for females prescribed nitrofurantoin. Initially, 0% of trimethoprim prescriptions were based on cultures or microbiology advice. Between December-February no instances of trimethoprim prescribing were observed, as alternative antibiotics had been correctly prescribed. 60% had documented clinical symptoms of a UTI across both time periods. A midstream specimen of urine (MSU) was sent for cultures and sensitivities for 65% of those sampled (June-August), increasing to 73% when reaudited (December-February).

Discussion/Conclusion
This audit has observed a significant improvement in the management of UTI’s in the over 65’s at Ringwood Medical Centre. When the search was re-run, trimethoprim was no longer prescribed inappropriately, and for females, course lengths of nitrofurantoin were standardised at 3 days in line with current guidance. The audit has since been extended to all practices within the Primary Care Network, promoting improvement across the Clinical Commissioning Group. Additional improvement to ensure the documentation of clinical signs and symptoms is important to ensure the exclusion of red flag criteria upon diagnosis. Limitations of this study include a lack of long term follow up and small sample size. Future work to evaluate the use of non-indicated antibiotics for the management of UTI would prove hugely beneficial, further improving antimicrobial stewardship, patient centred care and pharmacy practice within the local area.

References
1. Royal College of General Practitioners. Antibiotic Prescribing in Primary Care UTI Audit for NON-CATHETERISED patients OVER 65. 2021. Available from: https://elearning.rcgp.org.uk/mod/book/view.php?id=12652.
2. SCAN Guidelines. Urinary Tract Infections. 2021. Available from: https://viewer.microguide.global/SCAN/SCAN#content,76dd6f46-e50c-4a9b-ac53-a6b171323561.
3. National Institute for Health and Care Excellence. UTI (lower): Antimicrobial Prescribing. 2018. Available from: https://www.nice.org.uk/guidance/ng109/resources/visual-summary-pdf-6544021069. Pages 2-3.