1. Facilitators Notes
This focuses on UTI presenting in more complex patient groups. This is defined in this session as older people (>65 years), patients with catheters, and men. It discusses the correct use of urine culture in these groups and other considerations for management.
Facilitators may find it useful to highlight that within ScRAP there are two other UTI sessions available on acute uncomplicated, and recurrent, should participants wish to discuss these other areas as a follow on to this. This may help avoid discussion around these groups during this session, and allow you to keep the session focused on the aims and objectives, and to time available for the session.
Refer to the ScRAP resource pack for the full list of sessions available.

2. Facilitator notes
Aim and objectives as per slide
The aims and objectives were developed using intelligence from practice audit and literature search on what the areas for improvement were in a primary care setting, and what interventions could support a reduction in unnecessary antibiotic use.
This part of the session starts with the option of undertaking process mapping to establish what is currently happening in relation to the management of uncomplicated UTI in the group. If you are undertaking this please allow an hour in total for the session. Process mapping element is likely to take around 15 minutes to complete. This element requires that the all the people involved in every step of the process are present. If you have less than 60 minutes protected time available for this session consider moving directly to the case study.
The case study looks at diagnosis of UTI in the elderly (in this case in the care home setting). Information then follows on use of urinalysis in older people, followed by information on catheter associated UTI, and suspected UTI in men.

3. Facilitator notes
Process mapping is useful as it allows everyone in the group to understand each stage in the process, including those stages which they are not directly involved in. For UTI this is particularly important as there are multiple steps in the process, usually involving multiple people. It will quickly identify where there is inefficiency in a process such as duplication, unnecessary steps etc. It should also help the facilitator identify which parts of the session may require more focus and discussion.
It is important that all people involved in the process are included in the mapping.
To create a visual representation of all the steps it works well to have a blank sheet of paper on the wall and get people to write on post-it notes at the relevant points and stick these on.
The aim is to capture all the elements of the process as it currently happens. Other points to consider are:
GP decision making in whether to prescribe or not. What criteria are used? What questions do they ask? Does current practice match with the algorithm
For which patients do they use dipstick testing? Is this appropriate? What action would they consider following a positive result for one or more of the dipstick test parameters?
When would they send an MSSU?
What are their treatment choices both for antibiotics (type and duration) and alternative management/treatment?
Looking at the process map is their duplication, any unnecessary steps, unnecessary testing etc.
Explore and agree how these could be addressed and create an action plan on agreed changes with timescales.

4. Facilitator notes
GIVE COPY OF DECISION AID and use to work through following case. Where possible print double sided in colour and laminate for each participant.

5. Facilitator notes (N.B. do not read out to group)– this case is designed to highlight:
The important of appropriate assessment in the elderly (it may be worth checking how the practice currently communicates with care homes to receive and record information on symptoms)
The importance of not assuming ‘confusion’ means they may have a UTI and need treated ‘just in case’
Consideration of differential diagnosis (including delirium)
The incidence of bacteriuria in the absence of infection (treating the signs and symptoms and not the lab findings)
Suggested answers
Signs and symptoms may differ in the elderly (and catheterised) than those see in uncomplicated UTI
Start with systemic symptoms. Exclude other sources of infection before reviewing urinary symptoms.
More information would be required to identify why Agnes was confused and if she has delirium this would involve a detailed history, examination and where relevant investigations to identify and manage any underlying cause. Delirium is a medical emergency and may require admission.
Take a history from her/ informed observer (family member or carer) asking about:
The onset, nature, and course of the behaviour change — acute behaviour change (developing over hours or days) which fluctuates is suggestive of delirium.
Baseline functional and cognitive state. Is this an acute or chronic cognitive decline? Are there precipitating factors (new illness, environmental, sensory, medication)?
Examination –Check vital signs. Plus general assessment to identify any precipitating factors.
Cognitive assessment.-Note the 4AT can be used as an initial screening tool. Diagnosis can also be based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or the short Confusion Assessment Method (short-CAM).
Investigations of underlying causes
Depends on what was found during investigation.
As Agnes is not catheterised there should be at least one other sign of urine infection present in addition to new/worsening confusion or agitation to make a working diagnosis of UTI reasonable (dysuria, urgency, frequency, new/worsening urinary incontinence, rigors, pain in flank/suprapubic, frank haematuria).

6. Facilitator Notes - Suggested Answers:
There is not enough evidence to diagnose a UTI so other causes of her behaviour change should be considered (as previous slide)
She should not therefore be issued with an antibiotic for UTI ‘just in case’ as this potentially exposes Agnes to unnecessary risk (resistance, HAI, side-effects).
In this case it is likely that the urine culture results is positive due to colonisation (asymptomatic bacteriuria), which is not an indication for antibiotic treatment. Faecal contamination of samples can also occur in the elderly , especially if there is incontinence.
Samples should only be sent for culture when there are two or more relevant symptoms or one or more if catheterised. The role of the urine culture is to support a working diagnosis based on symptoms not to override symptomatic diagnosis.
In this case it is possible that she is constipated and this has put her off her food and drink – leading to worsening confusion. Her diet and laxative intake should be reviewed, and the care home staff should continue to monitor this.
Signposting delirium
Further learning on delirium is available via NES
The following resource contains a useful table comparing dementia, delirium, and depression which can be given as a handout if you wish to discuss this area in more detail (p )

7. Facilitator Notes
There is a high instance of asymptomatic bacteriuria in the elderly and this is NOT associated with increased morbidity
No evidence for using urinalysis to diagnose UTI in elderly. Use symptoms and signs.
All patients with indwelling catheters have bacteriuria, and colonisation increases the longer in (3-6% acquire/ day – SIGN ).
If antibiotics are given when not required this increases the risk of future UTI due to resistant bacteria.
If the patient did require antibiotics for future infections, this may limit antibiotic choice for treatment and has societal impact.
Antibiotics also alter the vaginal flora and may promote colonisation of the genital tract with E. coli, resulting in subsequent increased risk of urinary tract infections.
The elderly are also at increased risk of healthcare associated infections such as Clostridium difficile infection, and of drug interactions and side-effects.

8. Facilitator Notes
Both long term indwelling and intermittent catheterisation increase the risk of UTI, so use should be minimised where possible, and regularly reviewed to ensure that ongoing catheter use is appropriate.
Guidance on when to take the catheter specimen of urine (CSU) can vary. Please refer to local guidance if available to see whether this is recommended before or after the catheter change; or before or after starting antibiotics. The flowchart above assumes that the sample is taken before any other intervention. The most important thing is to try and get a fresh sample i.e. not from the bag!
It is important to remove/ change the catheter when there is a UTI. This should be done before or within 24 hours of starting antibiotics (refer to local policy). It is important to liaise with others involved in catheter care e.g. DN, care home.
There is a lack of evidence that antibiotic prophylaxis reduces the risk of CAUTI, including use of a single dose for catheter changes.
It is important to ensure appropriate catheter maintenance if removal is not an option
Nationally there is a ‘CAUTI bundle’ to support prevention of catheter associated UTI by improving insertion and maintenance which may be in use in your board (
The Scottish UTI Network are also developing a national version of the ‘catheter passport’ (pending) which is available already in some boards to support improved patient management through patient held information ( )
NES in collaboration with the care inspectorate also have information posters/ leaflets on good practice in catheter maintenance for care homes ( )

9. Facilitator Notes
History
Check for frequency, urgency, dysuria, nocturia, haematuria, suprapubic pain, fever, sexual history, genital discharge, genital discomfort
Possibility of sexually transmitted disease should always be considered (particularly in younger men)
Additional questions for male patients: poor stream, terminal dribbling, incomplete voiding, overflow incontinence? (particularly in older men)
Symptoms of UTI in men may suggest an underlying urological problem and a diagnosis of prostatitis should also be considered.
Examination
Abdominal, genital, pelvic and prostate examination and if appropriate, temperature, urine culture. Dipstick urinalysis would not normally be required, although PHE infection management guidance suggests that a negative dipstick may be a way to exclude UTI in is symptoms are mild/ non-specific.
Treatment
Important to ensure appropriate choice and duration – particularly if prostatitis suspected.
Little evidence for antibiotic prophylaxis in men – see SAPG link on slide
Refer for urological review in persistent or recurrent cases

10. Facilitator Notes
Empirical antibiotic choice will be determined by boards guidance which may depend on local resistance patterns
Antibiotic choice should be considered on a case by case basis, considering previous resistance and sensitivity patterns
Resistance can persist for up to 12 months in an individual
For older people; men; catheters- antibiotic choice should normally be based on culture sensitivities (start smart then focus)
If issuing a second antibiotic for persistent symptoms it is important to give a different antibiotic
Signposting References
Positive and negative predictive values for samples still being resistant/ sensitive to commonly used antibiotics at 3 months and up to 12 months
For persistent the guidance not to use the same antibiotic again are in line with guidance from the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2012]. The recommendation to offer a different antibiotic if symptoms persist is supported by a study of the course of uncomplicated community-acquired urinary tract infection in women [McNulty et al, 2006].

11. Facilitator Notes
Comprehensive history taking BEFORE prescribing
Consider differential diagnosis
Base diagnosis on systemic signs and symptoms (bacteriuria is NOT a disease)
Incomplete bladder emptying during micturation common cause
Only culture to confirm if infection and aid treatment choice if:
≥2 signs of infection
or if catheter ≥1 sign systemic infection (change catheter if starting antibiotics)
Test of cure not required
Prophylaxis for catheters not recommended
Always consider the risk of prescribing as well as the risk of not
*Treat the patient not the pee!*

12. Facilitator Notes
Hopefully if the practice has completed the pre-work there is an indication of what currently happens compared with what they have just heard. The next stage is for them to identify how they can improve adherence to guidance in relation to use of diagnostic testing to support treatment decisions.
Note that examples of improvement ideas will be available alongside the ScRAP resource e.g. NHS Grampian have done work with care homes to improve the assessment and recording of suspected UTI which has resulted in reduced antibiotic use. You may wish to check these out before delivering this session so relevant examples can be highlighted and discussed

13. Facilitator Notes
Go back to your original map of current processes and discuss elements that may require to be changed.
Agree how this will be implemented (consider creating a quality improvement plan)
If you are running out of time, arrange to revisit this at the next available practice meeting to ensure momentum for implementing change is maintained
Signposting further education
The practice may now wish to undertake the ScRAP sessions on uncomplicated and/ or recurrent UTI
An RCGP e-learning module (1.5hrs) is also available if further self learning is required