Facilitator Notes This focuses on recurrent UTI. It discusses the correct diagnosis of persistent / recurrent UTI, and the use of antibiotics in this context (see aims and objectives on next slide) Facilitators may find it useful to highlight that within ScRAP there are two other UTI sessions available on female uncomplicated and complicated UTI (older, catheterised, men), should participants wish to discuss these as follow on to this (if not already completed). 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).

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.

Facilitator notes (do not read out) This case is designed to highlight that failure to identify differential diagnosis can result in unnecessary treatment of unproven UTIs. This can lead to patients being labelled as recurrent UTI inappropriately.

Facilitators Notes Suggested Answers Invite for review/ examination: Clarify what urinary symptoms there are (actual listed on next slide) Check if she has experienced any vaginal discharge/ irritation Sexual history Date last menstrual period Consider abdominal and vaginal examination Recognise that in this case antibiotics were being prescribed in the absence of confirmed infection, and that choices and durations were not in line with recommendations even if infection had been present e.g. if trimethoprim had been given appropriately empirically there would be no rational to giving the same antibiotic again within 2 weeks

Facilitators Notes The slide above details the findings on questioning and examination It is anticipated that they will request a urine sample for culture to identify if she has a UTI – See next slide and refer to the algorithm at this stage

Facilitator notes PROVIDE COPIES OF THE ALGORITHM at this stage for reference (consider printing page 1 and 2 double sided in colour and laminated for ease of use) Supplementary information on vaginal atrophy The incidence of this is up to 50% in post menopausal women (although it is suspected this is under reported)1 Urinary symptoms associated with vaginal atrophy include frequency, urgency, and urge incontinence. In postmenopausal women local, vaginal oestrogen replacement, but not oral oestrogen, showed a trend towards preventing UTI recurrences, but vaginal irritation occurred in 6 - 20% of women2 Signposting references http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800285/ http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf

Facilitator Notes It is important to consider if all episodes of UTI were confirmed (by microbiology culture) before labelling a patient with recurrent UTI. It is also important to consider whether each episode represents a separate infection rather than a persistence of the initial infection due to inadequate treatment.

Facilitators Notes It is important that any assessment of a patient presenting with suspected UTI considers factors that could lead to a differential diagnosis and consider any follow up investigations required to support a diagnosis of recurrent UTI. Does the practice currently adopt history taking that would establish these factors?

Facilitators Notes Cranberry products (SAPG recurrent UTI guidance)1 Research suggests that cranberry products prevent bacteria (particularly E.coli) from adhering to epithelial cells that line the bladder wall. Note they are contra-indicated in patients on warfarin. A recent Cochrane review found no substantial reduction of risk of repeated UTI in women with cranberry products compared with placebo or no treatment.2 However when one large outlying trial was removed (which used lower thresholds for defining UTI) the relative risk (RR) of recurrent UTI was 0.58 (CI 0.39-0.86) suggesting that cranberry products may reduce the risk of recurrent UTI by 40%. Optimum doses and formulations have not been established. Alkalising agents A recent Cochrane review found a lack of suitable RCTs of alkalinising agents such as Potassium citrate and so there is a lack of evidence to support safety and efficacy3 From a pragmatic point of view although both high strength cranberry and alkalising agents are not supported by strong evidence they may offer a safer option for some patients if they prevent unnecessary antibiotic exposure and can be used for self-management. Patient Information Leaflets to Support Prevention / Self- Management A link is provided to patient.co.uk recurrent cystitis leaflet4 This leaflet may contain too much information for some patients and the advice within the recent Public Health England (PHE) /RCGP leaflet ‘UTI Information leaflet’ may be preferred. References SAPG recurrent UTI Guidance (https://www.scottishmedicines.org.uk/files/sapg1/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf ) Cochrane Review Cranberry http://www.cochrane.org/CD001321/RENAL_cranberries-for-preventing-urinary-tract-infections Cochrane Review - Alkalinising Agents http://www.cochrane.org/CD010745/RENAL_urinary-alkalisation-uncomplicated-urinary-tract-infections Patient.co.uk recurrent cystitis patient info leaflet RCGP TARGET Antibiotics Toolkit

Facilitator Notes The above flowchart is taken from the SAPG guidance on managing recurrent UTI in women

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 Where possible cultures should be taken in persistent and recurrent to confirm the presence of infection when there are suggestive symptoms, and results awaited before choosing a suitable antibiotic (if there is no risk of deterioration in interim). If issuing a second antibiotic for persistent symptoms it is important to give a different antibiotic

Facilitators Notes As required use (post-coital/ stand-by) could be considered in appropriate patients avoiding the need for daily antibiotic exposure. Where daily use necessary – give as a fixed course e.g. 3-6 months and enter stop/ review date in dosage directions The patient should be counselled at an early stage that antibiotic prophylaxis is not usually a life-long treatment. Avoid using prophylactic antibiotics in catheterised patients and men due to lack of evidence (and potential harm from development of resistance) See next slide for discussion points for stopping prophylaxis Signposting references SAPG Guidance Recurrent in women: https://www.scottishmedicines.org.uk/files/sapg1/Management_of_recurrent_lower_UTI_in_non-pregnant_women.pdf European Association of Urology – Guidelines on Urological Infections http://uroweb.org/wp-content/uploads/19-Urological-infections_LR2.pdf (informed 3 to 6 month duration in SAPG guidance) SAPG Guidance Recurrent UTI in men and prostatitis: http://www.scottishmedicines.org.uk/files/sapg/Advice_on_antibiotic_use_in_recurrent_UTI_in_men_and_prostatitis_2015.pdf

Facilitator Notes -Discussion Points When initiating antibiotics make it clear to the patient that this is a fixed course rather than longer term treatment. Explain antibiotics are given in this way to allow a period of bladder healing which makes UTI much less likely. There is no evidence antibiotics have any additional benefit beyond 6-12 months treatment therefore the treatment should be discontinued ideally after 6 months. (The European Association of Urology guidelines suggest 3-6 months as per previous slide) Patients may feel anxious about returning to suffering recurrent UTIs. They should be given appropriate advice regarding simple measures to prevent UTI. The risks of long term antibiotics in terms of vulvovaginal side effects, Clostridium difficile infection and increased likelihood of infection with resistant organisms are also important considerations for the doctor and patient and should be fully discussed. Always safety-net for reassurance What to do if the patient re-consults with suspected UTI? It is important to ensure the patient is complying as far as possible with the simple measures outlined previously (prevention). If they have not already had a renal tract ultrasound and post void bladder residual volume scan now is a good time to consider doing this in consultation with local specialists. In post-menopausal women consider the possibility of atrophic vaginitis as a risk factor for UTI and manage appropriately. If recurrent UTI is a relatively ‘new’ problem in a post menopausal woman consideration should be given to referral for cystoscopy. However, if appropriate investigations have already been done and shown no abnormality and there are no other concerning ‘red flag’ symptoms and cranberry products have already been tried (or are inappropriate e.g. if the patient is on warfarin) then continuation of prophylaxis may be considered. The ongoing need for antibiotic prophylaxis should be reviewed again after 3 months.

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.

Facilitator Notes Discuss elements of current processes 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/ group 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 complicated UTI An RCGP e-learning module (1.5hrs) is also available if further self learning is required http://www.rcgp.org.uk/courses-and-events/online-learning/ole/urinary-tract-infections.aspx