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 mental health trust CCG meds Optimisation team Local Authority CDDFT Acute Trust Neighbouring acute trusts NHSE PHE NECS CCG commissioning team • County Durham and Darlington Health and Social Care HCAI group • Infection Control Liaison Group • County Durham and Darlington Foundation Trust (CDDFT) Infection Control Committee • Primary care new build/refurbishment of premises meetings. • CDDFT Monthly HCAI meeting • County Durham and Darlington CCGs quality meetings • Care home manager forums • Provider Quality Review Group • Care Quality Commission (CQC) information sharing meetings • Safeguarding information sharing meeting • Urinary Catheter Group with CDDFT • Care Home Executive Strategy meetings • Sunderland CCG and South Tyneside CCG HCAI improvement group • County Durham and Darlington Area Health Protection Group • Post 72 hour Clostridium difficile appeals meeting • Pre 72 hour Clostridium difficile RCA meeting GP practice • Post 72 Clostridium difficile RCA meeting CDDFT • Pre and post 48 hour MRSA Bacteraemia meeting CDDFT • TB Strategy group meetings. • Cluster Investigation Team meeting • Health Research Methodologist Study, Durham University

Summer 2014 increased ESBL’s, GP surgeries states care homes handing lots of urine samples for no reason. SIGN guidelines Evidence based guidelines tend to focus on issues of antibiotic treatment with less emphasis on clinical diagnosis Plan of action visited 3 care homes within a practice population. Evidence based SIGN Training and working with GP surgery ESBl follow up patients and realised

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 Main reason staff send samples is for confusion and dark urine, Practice of dipsticking is all the healthcare workers Prevalence study on catheters faecal incontinence

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. To reduce esbl – appropriate prescribing Clinical presentation of uti In conjunction wit lab results.Barnard Castle one surgery 3 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                 

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. Joint working party with Acute trust to look at the 14 cases for CDDFT and then we then piloted a RCA for 8 cases in DDES using a new RCA visited GP surgeries

Care Home management of UTIs Resource packs distributed to all care homes Educational sessions delivered Patient symptoms form for referral for GP

Prevent UTI’s

Prevention is very important

Bacteria in the urine of older people Bacteria harmlessly live in the bladder of an older person: 100% 40% 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)

Often antibiotics are then prescribed inappropriately 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! Does this happen locally? Answer: It happens everywhere – worldwide research showing this sequence of events is very common in hospitals, primary care, care homes. Often antibiotics are then prescribed inappropriately

Antibiotics are powerful drugs Antibiotics are precious drugs 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 Antibiotics are the only drug where the more you give them, the less they work!

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 GPTeamNet

DDES trimethoprim to nitrofurantoin ratio Shows CCG switch from trimethoprim to nitrofurantoin, and compared to rest of country

Trimethoprim items in over 70s Shows reduction in trimethoprim items in over 70s

DDES total items per STAR-PU Not seeing significant reductions in items per star-pu, and still above national target, and far above national average.

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 Team 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 CSUs 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 Nov dec 2017 all wards and comm hospitals Back of audit government recommendations Every ward Target all staff Brief presentation UTI dx mngx prevention Feedback staff – good practices – hydration charts, not dipsticking Picked up some issues – falls ass Based on audit findings knew which wards main culprits

Obstacles What we realised that individuals and separate teams across the health economy were doing different things GP surgeries dipstick testing, limiting care homes to white bottles, requested repeat urine samples Mental health: dipstick urine before mental health assessment Ambulance service, dipstick urines OOH not following guidelines Acute Trust, dipstick all urines and do not send off MSU/CSU Tried to address each area, NEAS, mental health, acute Changing in the health teams eg federation, wrap around teams, TAPs.

How do we go forward? Better to prevent infection from occurring in the first place Strengthen community base IPC Improve accuracy of diagnosis and treatment of UTI in older people Prevent UTI in over 65 hydration reduce catheter use 4. Improving antimicrobial therapy

Development of Protocol for the Diagnosis and Management of UTI for over 16 years non pregnant women and men Standardised document for consideration of adoption within GP practices Includes information on use of dipsticks, sending samples and treatment algorithms Developed with CDDFT Microbiologists and Pathology lab Includes patient referral forms for completion on handing in samples Also combined with posters for Patient waiting rooms on dehydration and UTI management

Key points of guidelines 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. Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly increased risk of clinical adverse events including the development of antibiotic-resistant UTIs Awareness of all primary staff regarding urine dipstick testing in catheterised patients and those >65 years to be raised Dipsticks NOT to be used to diagnose UTIs in elderly or catheterised patients.

RightCare GU Project Hydration Catheter Care GNBSI NEAS / 111 Coding PINCH ME

Hydration

Reduce catheter usage HOUDINI to empower nurses to remove catheters Catheter formulary Centralised catheter prescribing

Different work streams AMR, PHE, CCG’s

Who is involved in reducing the target? Reduction in Gram Neg. bacteraemia cases PHE North , AMR group , health protection leads, PHE AMT, Trust led, NECS IPCT Trust HCAI forum operational Other CCG – HCAI forum Collaborative working CCDFT, CCG, PH, LA, GP’s , 3 work streams NE AB pharmacist group secondary care HCAI assurance group, LA, CCG, Trusts NHS and Private , PHE AMR/ HCAI Forum NECS primary care AB group NE region , microbiologists, PHE Catheter, group CCDFT, CCG Performance within commissioning Quality meetings AMR Deepa had a meeting to look at work streams and develop a plan across the health economy

For the gram negative target to be achieved we have to work like this… Health economy wide meeting NHSE

Thanks for listening….. Any Questions?