31.4 million antibiotic items were prescribed in primary care in 2019/20, at a cost of £165 million. 22% (7.0 million) of these items were for antibiotics commonly prescribed in primary care to treat lower UTI at a cost of £47.6 million, and 41% (2.73 million) of these antibiotics were prescribed to people aged 70+ years.
Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly increased risk of clinical adverse events, including Clostridium difficile or methicillin-resistant Staphylococcus aureus infections, infection with multi-drug-resistant gram-negative organisms including extended-spectrum beta-lactamase organisms and carbapenem-resistant Enterobacteriaceae, and the development of antibiotic-resistant UTI[i]
This video by Health Education England support health and care workers looking after older adults with suspected urinary tract infections (UTIs) and introduces resources that can be used to diagnose, manage and prevent UTIs in the out of hospital setting.
The potential benefits of ensuring the appropriate diagnosis, treatment and prevention of UTIs include:
- reduced progression to more serious conditions such as pyelonephritis and sepsis,
- reduced hospital admissions,
- reduced morbidity and mortality and,
- reduced antimicrobial resistance within the community.
Nitrofurantoin and trimethoprim account for 84% of the 7.0 million antibiotic items commonly prescribed to treat lower UTI in primary care, with 39% of items prescribed to people aged 70+ years. Nitrofurantoin is reported to have the lowest rate of resistance in all age groups and Pan Mersey & NICE guidelines recommend nitrofurantoin as a first choice antibiotic to treat lower UTIs in adults and children, with trimethoprim an alternative choice if the patient is known to have a low risk of resistance. Despite this, 43% of all trimethoprim items are prescribed for people aged 70+ years who are more likely to have a higher risk of trimethoprim resistant UTI. Inappropriate management of a UTI can result in a treatment failure and increase the risk of E.coli bacteraemia.
Historically, urine dipsticks have been used as a tool to aid the diagnosis of UTI. Bacteria in the urine does not always mean an infection is present. In older people, bacteria can live harmlessly in the bladder without causing any harm to the person. This is known as asymptomatic bacteriuria, it is not an infection and treating with antibiotics does not prevent further infections and may cause harm. It has been shown in older people, that up to:
- 40% of men
- 50% of women
- 100% of people with long term catheters
Will have bacteria in their urine without signs or symptoms of infection.
Therefore, urine dipsticks are no longer recommended in the diagnosis of UTI in older people. This is because urine dipsticks cannot differentiate between bacteria that cause an infection and those that are living in the urine harmlessly. Urine dipsticks are contributing to unnecessary antibiotic use and missing the real diagnosis. An assessment of signs and symptoms is more accurate. NICE recommends:
- Dipstick testing should not be used to diagnose UTI in people over the age of 65 with possible UTI
- Dipstick testing should not be used to diagnose UTI in adults with urinary catheters.
- People over the age of 65 and those with urinary catheters should be clinically assessed prior to being diagnosed with a UTI
For further information on the diagnosis, management and prevention of UTI, please refer to the following:
- Pan Mersey Antimicrobial Guidelines – Urinary Tract Infection
- Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care for consultation and local adaptation. October 2020.
- Urinary Tract Infection in Adults. Quality Standard 90. June 2015.
- Pyelonephritis (acute): antimicrobial prescribing. NICE Guideline NG 111. October 2018.
- Urinary tract infection (recurrent): antimicrobial prescribing. NICE Guideline NG 112. October 2018.
- Prevention, recognition and management of urinary tract infections (UTIs). February 2021.