Management of suspected bacterial urinary tract infections A team Approach Jane Lawson Senior Infection Prevention and Control Nurse Durham dales Easington Sedgefield , North Durham and Darlington CCGs
IPCT team and the wider Health Economy CQC Local CCG mental commissioning health team trust CCG meds NECS Optimisatio n team IPCT Local PHE Authority CDDFT NHSE Acute Trust Neighbourin g acute trusts
Further investigation • Increased incidence of ESBL – extended spectrum beta lactamase in urine samples in care homes • Care home staff not always aware why sample sent • Lack of understanding of signs and symptoms of UTI’s • Lack of understanding of catheter care • Not maintaining personal hygiene when changing incontinence pads • Practice of using diagnostic sticks to confirm UTI. • Professionals prescribing antibiotics on the result of dipstick
Approach to change : Pilot proposal • Discussed problem with lead PN in GP surgery • Reviewed existing urine sample submission forms • Developed new form for care home staff to complete • Introduced diagnostic flow chart for care home staff base on SIGN • Discussed planned approach with GP’s, community matrons, microbiologist and care home managers • Resource pack developed and launched within the three targeted care homes.
After 3 months After 3 months: • care home staff no longer dipsticking urine samples • care home staff documenting why sample has been sent • verbal feedback from all involved indicate that less samples have been sent • GP’s still requesting staff to dipstick urines • HCA’s working in surgery continue to dipstick urine
DON Prospective “ As Executive Director of Nursing and Director of Infection Prevention and Control and on behalf of the Foundation Trust board; I can say we are very supportive of the collaboration between the Foundation Trust and CCG teams, in their aims of reducing HCAI infections specifically GNBSIs. We cannot achieve this reduction by working in isolation. The team demonstrate strong leadership and vision to drive this agenda forward, to achieve improved health outcomes and better experience for all our patients across the whole health and social care sector. We look forward to widening this collaborative working across the region” Noel Scanlon , Executive Director of Nursing, County Durham and Darlington NHS Foundation Trust “As a health economy we are working very closely together on this agenda to make sure that the changes we make are agreed, understood and implemented across primary, community and secondary care. Our Boards and Governing Bodies have been involved from the start and receive regular updates. They are very supportive of the staff engaged in this important work” Gill Findley , Director of Nursing, Durham Dales, Easington and Sedgefield CCG and North Durham CCG www.cddft.nhs.uk
Themes identified from the RCA’s • Incorrect labelling of urine samples and labelling of specimens not consistent as CSU or MSU • <65 years of age patient, diagnosis of UTI made on admission on a positive dipstick and no MSU sent to confirm diagnosis or to establish sensitivities for antibiotics prescribing. • History of UTI’s stated on admission but no MSU’s been sent in last 5 months • Diagnosis of uro-sepsis but MSU NAD • Urology OPD letter requested GP to prescribe antibiotics on the strength of a positive dip test, no symptoms documented. • Problems with catheter management in care home by community nursing team, antibiotics prescribed because of a positive dipstick, catheter changed to size 18 for bypassing, • HCA in the surgery dip tested urine and requested antibiotics from GP- duly prescribed , no symptoms documented, no MSU sent.
Care Home management of UTIs • Resource packs distributed to all care homes • Educational sessions delivered • Patient symptoms form for referral for GP
Dehydration Urine Colour Chart Probably well hydrated. Drink water as normal. Could stand to drink a little water now, maybe a small glass of water. Drink about 1/2 bottle of water (1/4 litre) within the hour, or drink a whole bottle (1/2 litre) of water if you're outside and/or sweating. Drink about 1/2 bottle of water (1/4 litre) right now, or drink a whole bottle (1/2 litre) of water if you're outside and/or sweating. Drink 2 bottles of water right now (1 litre). If your urine is darker than this and/or red or brown, then dehydration may not be your problem. Seek further advice.
Fluid Matrix Chart Residents should aim to drink about 8 mugs of fluid each day. If they do not drink enough they will produce concentrated urine. This is a guide for the recommended amount of fluid they should drink per day based on their weight. Weight Weight mls Fluid Pints Mugs stones Kg ozs 6 38 1,190 42 2.1 4 7 45 1,275 49 2.5 5 8 51 1,446 56 2.75 5-6 9 57 1,786 63 3.1 6 10 64 1,981 70 3.5 7 11 70 2,179 77 3.75 7-8 12 76 2,377 84 4.2 8 13 83 2,575 91 4.5 9 14 89 2,773 98 4.9 10 15 95 2,971 105 5.25 10-11 16 102 3,136 112 5.5 11 This matrix is to be used as a guideline and broadly it is suggested that patients fall within a margin of error of +/- 10%. The guideline applies to body frame and gross obesity should not be taken as a guide for increasing fluid. Abrams & Klevmar “Frequency Volume Charts – an indispensable part of lower urinary tract assessment” 1996 Scandinavian Journal of Neurology 179; 47 - 53 Date: February 16 IPC team
Bacteria in the urine of older people • Bacteria harmlessly live in the bladder of an older person: 40% 100% What effect does this have on the urine dipstick? 50%
What is best practice for UTI? • National Guidelines: • “ People >65 years should have a clinical assessment before being diagnosed with UTI” (NICE) • “ Do not use urine dipstick testing in the diagnosis of older people with possible UTI” (SIGN) • “ Do not use dipstick testing to diagnose UTI in adults with urinary catheters” (NICE)
No dipstick – really?? 50% 40% 100% Urine dipstick will be positive for nitrites and leucocytes... But doesn’t tell us if it is an infection or not! Often antibiotics are then prescribed inappropriately
More harm than good? Antibiotics are powerful drugs Antibiotics are precious drugs Giving an older person antibiotics when they don’t really need them can lead to: • Side-effects such as rashes & stomach upsets • C.diff diarrhoea which can be life-threatening • Antibiotic resistance so antibiotics won’t work when the person really does need them 1 in 3 older people will suffer side-effects from antibiotics if given them when they don’t need them
Remember • In people aged over 65 years, asymptomatic bacteriuria is common, but is not associated with increased morbidity. • Elderly institutionalised patients frequently receive unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.
Local work – Antibiotic prescribing • Fair Funding Scheme 17-18 targets to encourage switch to nitrofurantoin in-line with guidance • Fair Funding Scheme 17-18 targets to encourage reduction in total antibiotic prescribing • Regular reporting of trimethoprim in over 70s and 3C prescribing via monthly prescribing reports • Education sessions in LPGs, – UTI management – National AMR campaign • UTI and AMR campaign resources available on GPT eamNet
DDES trimethoprim to nitrofurantoin ratio
Trimethoprim items in over 70s
DDES total items per STAR-PU
Local work – catheters • Catheter group and work with Patient Hand held records • Education sessions for GP admin, practice pharmacists and at LPGs about catheters • Developed an information packs about catheters for use in primary care • Ongoing work with Continence T eam at CDDFT to develop a catheter formulary
Local work streams – secondary care • Analysis of data • Sepsis • Antimicrobial stewardship • Prevention / diagnosis / management UTI – HOUDINI – ISC catheterisation – UTI walk rounds – Urine dipstick audits
MSUs >65 years • Clinical details not stated (78/178) = 44% • Abx not stated (163/178) = 92% CSUs • Clinical details not stated (25/44) = 57% • Abx not stated (39/44) = 87%
UTI walk rounds • UTI diagnosis, management and prevention • Every ward, all staff • Brief presentation and discussion • Delivered posters and freebies • Designed poster focussing on UTI dx • Patient held record – urinary catheterisation • Feedback – Falls assessment
How do we go forward? Better to prevent infection from occurring in the first place 1. Strengthen community base IPC 2. Improve accuracy of diagnosis and treatment of UTI in older people 3. Prevent UTI in over 65 hydration reduce catheter use 4. Improving antimicrobial therapy
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