Health Protection Agency: uncomplicated urinary tract infections audit in primary care

Transcription

1 Health Protection Agency: uncomplicated urinary tract infections audit in primary care Aim of audit To evaluate the diagnosis of uncomplicated urinary tract infections using urine dipsticks and/ urine cultures and to assess antibiotic prescribing using Health Protection Agency guidance on the diagnosis antibiotic treatment. Audit requirements Consultation recds with the following clinical conditions ( the cresponding read code) need to be searched f: K15: Cystitis K190: Urinary Tract Infection IJ4: Suspected UTI K190z00: Urinary Tract Infection, site not specified NOS Ideally, there should be at least 20 consultations analysed to determine overall compliance. Method Please view Figure 1: HPA Quick reference guide f primary care to assess your practice s your individual compliance with the recommended algithm visit the website f me infmation and the rationale behind the recommendations Please view Table 2: HPA management f infection guidance in primary care to determine the proption of your patients who have been prescribed the recommended antibiotics, including dose, frequency and duration. You can visit the website f me infmation and the rationale behind the recommendations You may wish to use your local primary care ganisation s guidance as an alternative. Results Table 1 (overleaf) shows the results that should be recded. 1

2 Table 1: Assessing compliance with HPA guidance Total number of patients being audited Use Figure 1 to determine the total number of patients given empirical antibiotics appropriately in line with guidance without use of dipstick Use Figure 1 to determine the total number of patients in which urine dipsticks were used appropriately in line with guidance Total number of patients prescribed an antibiotic Use Table 2 to determine the total number of crect antibiotics chosen Use Table 2 to determine the total number of crect doses Use Table 2 to determine the total number of crect treatment frequencies Use Table 2 to determine the total number of crect antibiotic course lengths A B C D E F G H Calculations: % compliance with HPA UTI diagnostic guide = (B+C/2A) x 100 % compliance with HPA antibiotic Primary Care guidance = ((E + F + G + H) / 4D) x 100 Actions: Recd actions required, especially when compliance with UTI diagnostic primary care guidance is less than 80%: Identify a date when you will repeat the audit: The TARGET Antibiotics Toolkit provides guidance and other suppt to clinicians and commissioners to improve responsible antimicrobial prescribing in primary care. The Toolkit can be accessed at: 2

3 Figure 1: Diagnosis of UTI quick reference guide f primary care Diagnosis of UTI Quick Reference Guide f Primary Care URINARY SYMPTOMS IN ADULT WOMEN <65 DO NOT CULTURE ROUTINELY In sexually active young men and women with urinary symptoms consider Chlamydia trachomatis Severe 3 symptoms of UTI Dysuria Frequency Suprapubic tenderness Urgency Polyuria Haematuria AND NO vaginal discharge irritation 90% culture positive Give empirical antibiotic treatment Mild 2 symptoms of UTI (as above) Obtain urine specimen Urine NOT cloudy 97% NPV Consider other diagnosis URINE CLOUDY Perfm urine dipstick test with nitrite When reading test WAIT f the time recommended by the manufacturer Positive nitrite, and leucocytes and blood 92% PPV positive nitrite alone Probable UTI Treat with first line agents on local HPA Guidance Negative nitrite Positive leucocyte UTI other diagnosis equally likely Review time of specimen (mning is most reliable) Treat if severe symptoms consider delayed antibiotic prescription and send urine f culture Negative nitrite, leucocytes and blood 76% NPV negative nitrite and leucocyte positive blood protein Labaty microscopy f red cells is less sensitive than dipstick UTI Unlikely Consider other diagnosis Reassure and give advice on management of symptoms 3

4 Table 2: HPA management f infection guidance in primary care MANAGEMENT OF INFECTION GUIDANCE FOR PRIMARY CARE FOR CONSULTATION & LOCAL ADAPTATION 2012 People > 65 years: do not treat asymptomatic bacteriuria; it is common but is not associated with increased mbidity Catheter in situ: antibiotics will not eradicate asymptomatic bacteriuria; only treat if systemically unwell pyelonephritis likely Do not use prophylactic antibiotics f catheter changes unless histy of catheter-change-associated UTI trauma (NICE & SIGN guidance). Refer to the following weblink f the full guidance of the management of urinary tract infections: Adults (no fever flank pain) SIGN, Acute prostatitis BASHH, UTI in pregnancy Women severe/ 3 symptoms: treat Women mild/ 2 symptoms: use dipstick and presence of cloudy urine to guide treatment. Nitrite & blood/leucocytes has 92% positive predictive value; -ve nitrite, leucocytes, and blood has a 76% NPV Men: Consider prostatitis & send pre-treatment MSU OR if symptoms mild/non-specific, use ve dipstick to exclude UTI. Send MSU f culture and start antibiotics. 4-wk course may prevent chronic prostatitis Quinolones achieve higher prostate levels Send MSU f culture and start antibiotics Sht-term use of nitrofurantoin in pregnancy is unlikely to cause problems to the foetus Avoid trimethoprim if low folate status on folate antagonist (eg antiepileptic proguanil) trimethoprim nitrofurantoin 200mg BD 100mg m/r BD Women all ages 3 days Men 7 days Second line: perfm culture in all treatment failures Amoxicillin resistance is common; only use if susceptible Community multi-resistant Extended-spectrum Betalactamase E. coli are increasing: consider nitrofurantoin ( fosfomycin 3g stat in women plus 2 nd 3g dose in men 3 days later), on advice of microbiologist ciprofloxacin ofloxacin 2 nd line: trimethoprim First line: nitrofurantoin if susceptible, amoxicillin Second line: trimethoprim Give folate if 1st trimester Third line: cefalexin 200 mg BD 200 mg BD 100 mg m/r BD 500 mg TDS 200 mg BD (offlabel) All f 7 days 4

5 UTI in children NICE Acute pyelonephr -itis Recurrent UTI in nonpregnant women 3 UTIs/year Child <3 mths: refer urgently f assessment Child 3 months: use positive nitrite to start antibiotics. Send pretreatment MSU f all. Imaging: only refer if child <6 months, recurrent atypical UTI If admission not needed, send MSU f culture & sensitivities and start antibiotics If no response within 24 hours, admit Cranberry products OR Post-coital OR standby antibiotics may reduce recurrence. Nightly: reduces UTIs but adverse effects Lower UTI: trimethoprim nitrofurantoin if susceptible, amoxicillin Second line: cefalexin Upper UTI: co-amoxiclav Second line: cefixime ciprofloxacin co-amoxiclav Antibiotics: nitrofurantoin trimethoprim 500/125 mg TDS mg 100 mg Lower UTI 3 days Upper UTI 7-10 days 7 days 14 days Post coital stat (offlabel) Prophylaxis OD at night 5