Management of urinary tract infections in the community: a clinical audit and patient survey

Summary

The study has suggested that the degree of knowledge and familiarity that a patient has of UTIs may influence how they self-manage and consult healthcare professionals. The study has identified significant evidence suggesting male patients are less likely to try to manage symptoms themselves and they delay consulting a healthcare professional. Furthermore, across all patients, a lack of documentation of absence or presence of symptoms and an inappropriate use of both dipstick urinalysis and MSU microbiological culture by clinical staff appear to coincide, which may negatively impact on clinical guideline adherence.

Strengths and limitations

A large sample of patients were invited to participate in this study and therefore the cohort was able to be stratified by sex and age-specific UTI clinical guideline. The sample size for the male cohort was smaller, although UTIs are less common in males than in females. Males were included in this study and the focus was on patients who were living independently and not living in a residential or care home, in contrast to previous studies.^4,6,11 The response rate of just under 30% for the surveys is lower than reported for studies conducted face to face in the general practice but near-identical to a recent postal survey study conducted in the same general practices.^12,13 Non-responder bias may therefore be a risk and limit generalisability of the findings;¹⁴ the average age of survey responders, for instance, was higher than for those invited to complete the survey. The intention and strength of the study was to be able to cross-reference patient feedback and medical records for an index UTI episode. Validated measures were used where possible for the patient survey and the audit.^7,9 Reliance on GP documentation and patient’s memory of their consultation (up to 6 months previously) may not give the complete picture of what happened in real-time during the consultation. It is plausible GPs did adequately assess UTI symptoms but failed to document this, despite negative findings being as important as positive ones. Outcome measures used in previous papers on the topic were deployed too, such as self-treatment options used by patients, as described by Butler and colleagues.⁴

Comparison with existing literature

There is little available literature investigating the patient’s circumstances before consulting about their UTI symptoms. Of patients presenting with UTI symptoms, Butler et al recorded the use of cranberry juice, the number of days of symptoms, and number of days off work, but the corresponding discussion of these was limited.¹⁵ The patient’s view of having and managing a UTI has been explored in isolation in a number of studies. One — involving just females in the UK — found that virtually all women (95%) sought advice from a healthcare professional.⁴ In that cohort, the majority of patients consulted a general practice yet a substantial 13% contacted a pharmacist; the latter was also observed in the present study's data (see Table 1). The present study's sub-cohort of female patients took similar self-management steps, as reported previously for the female cohort in the Butler et al study. An assessment of the validity of these measures — which in the case of, for example, hydration and cranberry product consumption for the treatment rather than prevention of UTIs is debatable^16,17 — was beyond the scope of this study. The TARGET patient information leaflets do recommend hydration to all patients and do highlight the lack of evidence for cranberry products.¹⁸ The provision of the TARGET UTI patient information by clinical staff was very rare in this cohort and does not seem to be an established practice, as observed in another study.¹⁹ The rates for clinical staff providing generic symptom management and also safety-netting advice were near identical to those observed by others.^4,19

Poor recording of the absence or presence of UTI symptoms, as well as often inappropriate use of dipstick urinalysis and mid-stream urine (MSU) microbiological culture, contributed to low level of compliance with antibiotic stewardship in this cohort. In another study that audited cases using the TARGET tool, higher compliance was found.¹⁹ Although the present study started when there were still some severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) restrictions in place, meaning some consultations were not face to face when usually they would have been, it is recognised that variability in clinical practice is a long-standing issue.²⁰ Furthermore, the ability to record symptoms should not be affected by the mode of patient consultation. The finding that males are less knowledgeable about the UTI condition and are less pro-active to self-manage is concerning since (older) males are more prone to septicaemia.²¹ It cannot be concluded if the finding of more male patients being seen face to face in this study sample is an active mitigation practised by general practice staff or if it is a result of male patients preferring to be seen in this manner (and it therefore inadvertently contributed to delays in being seen by a healthcare professional owing to longer waiting times for face-to-face consultations).

Implications for practice

Both patient and clinician behaviours regarding general self-help measures and knowledge of points of care access, along with the distribution of UTI-health education materials would benefit from improvement. Different initiatives to improve self-management by males have already shown to have a degree of effectiveness, and may therefore have scope as a wider public health initiative.²² Female patients in particular apply self-management measures, such as cranberry product and over-the-counter cystitis product use, despite limited evidence that these may alleviate or treat acute UTI symptoms.^16,17 During consultation, clinicians can improve information provision to patients such as distributing the TARGET UTI information leaflets. Adjunct professions, such as pharmacists, could contribute in a similar fashion, although the study identified that unfortunately males presently visit such locations less frequently than females.

The different approach required to diagnose and manage UTI depending on patient age and sex appears to be a challenge for healthcare professionals in primary care, despite age and sex-specific national clinical guidelines having been in place for a number of years. Antimicrobial stewardship will be suboptimal if younger females continue to be prescribed antibiotics when they are not indicated; a delay in prescribing may be prudent, as demonstrated in a past randomised controlled trial.²³ Conversely, although there is increasing evidence to prescribe immediate antibiotics for male patients, insufficient MSU microbiological culture sampling may potentially increase the inappropriate prescription of antibiotics.^21,24 How feasible it is to achieve improvements in clinical practice in general practices will be the challenge, since it is known that time pressure erodes adherence to clinical guidelines.^6,25