CEPP National Audit – Focus on Antibiotic Prescribing
3. ANTIBIOTIC PRESCRIBING FOR UTI IN FEMALES
Background
AWMSG NPI: Antibacterial items per 1,000 STAR-PUs
The development of antibiotic NPIs supports one of the core elements of the Welsh Antimicrobial Resistance Programme: to inform,
support and promote the prudent use of antimicrobials.
Information from PHE Management of Infection Guidance for Primary Care for Consultation and Local Adaptation1:
Illness
Comments
Medicine
Adult dose
Duration of treatment
Treat women with severe/or ≥ 3 symptoms
nitrofurantoin
100 mg m/r BD
Women mild/or ≤ 2 symptoms AND
trimethoprim7B+
200 mg BD
Women all ages: 3
a) Urine NOT cloudy 97% negative predictive value
days2,12,13A+
pivmecillinam
400
mg
STAT
then
200
mg
TDS
(NPV), do not treat unless other risk factors for
UTI in adults
Men: 7 days1,5C
If
organism
susceptible
infection
500 mg TDS
(no fever or
b) If cloudy urine use dipstick to guide treatment. amoxicillin14B+
flank pain)
Nitrite plus blood or leucocytes has 92% positive
PHE URINE
predictive value; nitrite, leucocytes, blood all Use nitrofurantoin first line as general resistance and community multi-resistant
SIGN
negative 76% NPV4AExtended-spectrum Beta-lactamase E. coli are increasing. Trimethoprim (if low risk of resistance)
CKS women
c) Consider a back-up/delayed antibiotic option20A
and pivmecillinam are alternative first line agents.
CKS men
Men: Consider prostatitis and send pre-treatment Risk factors for increased resistance include: care home resident, recurrent UTI,
RCGP
UTI
MSU1,5C OR if symptoms mild/non-specific, use hospitalisation >7d in the last 6 months, unresolving urinary symptoms, recent travel to a country
clinical
negative dipstick to exclude UTI6C
with increased antimicrobial resistance (outside Northern Europe and Australasia) especially
module
Always safety net.
health related, previous known UTI resistant to trimethoprim, cephalosporins or quinolones 19
SAPG UTI
24-5
First line: Nitrofurantoin if GFR over 45 ml/min
If increased resistance risk, send culture for susceptibility testing & give safety net advice. If
GFR 30–45: only use if resistance and no GFR<45 ml/min or elderly consider pivmecillinam 21-3, 28 or fosfomycin (3 g stat in women15,16B,17A
alternative
plus 2nd 3 g dose in men 3 days later18)
In treatment failure: always perform culture1B
Signs and symptoms of a UTI are dysuria, urgency, frequency, polyuria, suprapubic tenderness and haematuria.
1,2A,3C
8B+ 9C 10B+
11C
SIGN 88 states:
 Do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters2.
 Consider antibiotic prophylaxis in patients for whom infections are of such frequency or severity that they chronically impinge on
function and well-being2. When changing catheters, antibiotic prophylaxis should only be used for people with a history of
catheter-associated urinary tract infection following catheter change2.
NICE Quality Standard 90 (QS90) published in June 2015 provides the following quality statements on UTIs in adults:
 Statement 2. Healthcare professionals do not use dipstick testing to diagnose urinary tract infections in adults with urinary
catheters.
 Statement 4. Adults with a urinary tract infection not responding to initial antibiotic treatment have a urine culture.
 Statement 6. Healthcare professionals do not prescribe antibiotic prophylaxis to adults with long-term indwelling catheters to
prevent urinary tract infection unless there is a history of recurrent or severe urinary tract infection3.
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All Wales Medicines Strategy Group
Method
There are two options for this audit section:
 Method 1 identifies women with urinary infection.
 Method 2 identifies people with indwelling urinary catheters.
Start the searches using a 3-month window and extend it if necessary to reach the required number of cases.
Following the audit, complete the Review Sheet and ensure that this includes achievement against the NICE Quality Standards.
Method 1: Women with urinary tract infection
Assess a reasonable sample of records with a diagnosis of UTI (female only) (see section on Sample size). Exclude pregnant females,
men, children and patients with acute pyelonephritis. Please note that the advice to record the cloudiness of urine is new (2014) and may
not be recorded in consultations for the first cycle of the audit. Search using the following Read Codes:
R081
K15
K190
1J4
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Dysuria
Cystitis
Urinary tract infection
Suspected UTI
CEPP National Audit – Focus on Antibiotic Prescribing
Data collection sheet (Method 1)
Patient
Cloudy
urine?
(Y/N/not
recorded)
≤2
symptoms
? (Y/N)
≥3
symptoms
? (Y/N)
Antibiotic
given?
(Y/N)
Where
antibiotic
given, were
there either 3
or more
symptoms or
a positive
urine dip
recorded?
(Y/N)
Trimethoprim
or
nitrofurantoin
? (Y/N)
90%
95%
Other
antibiotic
(record
name and
reason,
where
given)
Antibiotic
course
length
(number of
days)
No fever or
flank pain,
course
length = 3
days
(Y/N/Not
applicable)
If second course of
antibiotics for same
episode of infection,
was a midstream
specimen of urine
(MSU) sent?
(Y/N)
If single course of
antibiotics given, leave
blank
Total
% Yes
Standard
Locally defined
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All Wales Medicines Strategy Group
Method 2: People with indwelling urinary catheters
Identify a reasonable sample of patients who use indwelling urinary catheters (see section on Sample size). In primary care, methods to
identify patients using catheters will vary between practices.
Consider:
(i) Electronic identification. Search for patients who have had an acute/repeat prescription for catheter items issued in the
last 3 months. This report will include catheters issued for intermittent self-catheterisation. Before undertaking the audit,
confirm that the patient has an indwelling urinary catheter. These are issued in small numbers unlike intermittent catheters
which are normally issued in larger quantities e.g. over 28/month.
(ii) Informal enquiry of nursing home and care homes or the district nursing team.
Following the audit, complete the Review Sheet.
Data collection sheet (Method 2)
Patient
Antibiotics for urinary
infection in the last 12
months: None, Acute (A),
Prophylaxis (P)?
(A) + (P)?
Acute infection
Was the latest suspected
infection investigated with
dipstick testing? (Y/N/no
suspected infections)
Total
Number patients reviewed =
None =
A=
P=
Number y/number of patients
with suspected acute infections
% Yes
A + P/number reviewed x
100
Standard
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0%
Other reasons given
for prescribing (urinary
tract) antibiotics
Are these reasonable
indications?
Prophylaxis? (Y/N)
Number y/number of
patients reviewed
To be agreed locally.
Suggest less than 10%
Prophylaxis
History of frequent & severe
urinary infections?
Catheter change prophylaxis:
history of UTI following
catheter change?
(Y/N/uncertain)
Number y/number of patients on
prophylaxis
100%
CEPP National Audit – Focus on Antibiotic Prescribing
REFERENCES
1 Public Health England. Management of infection guidance for primary care for consultation and local adaptation. 2014. Available at:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377509/PHE_Primary_Care_guidance_14_11_14.pdf.
Accessed Feb 2015.
2 Scottish Intercollegiate Guidelines Network. SIGN 88 Management of suspected bacterial urinary tract infection in adults. 2012.
Available at: http://www.sign.ac.uk/pdf/sign88.pdf. Accessed Mar 2015.
3 National Institute for Health and Care Excellence. Quality Standard 90. Urinary tract infections in adults. Jun 2015. Available at:
https://www.nice.org.uk/guidance/qs90/resources/guidance-urinary-tract-infections-in-adults-pdf. Accessed Jun 2015.
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