1. Urinary Tract Infections and AKI 3rd Annual Practice Nurse and HCA Conference 2017
“To Dip or Not To Dip?”
Thank you so much to all the organisers for arranging …..pleased to be asked .
I am a pharmacist working at ENH CCG and amongst my responsibilities is that of antibiotic prescribing. As I hope I will demonstrate the use of Abx in Utis in general and elderly pts in particular problem is often suboptimal.
Before I start I would like to gauge your understanding of a fundamental aspect of UTIs …that of diagnosis. Can you raise your hand if you think we should use urine dip sticks to diagnose UTI in elderly?
OK that poses the question to dip or not to dip. This will be the essence of the presentation.

2. Quiz 1. How much urine does the average adult produce a day?
1.5 gallons pints litres
2. Who is at greater risk of UTI in the older population?
Men Women No difference
3. What time of year are UTIs more common?
New Year Spring Summer
4. What percentage of care home residents are prescribed an antibiotic for UTI in a year?
19% 28% 43%
Women are at greater risk overall, but men seem to get more severe infections (higher rates of E.coli bloodstream infections).
Summer peak – thought to be due to dehydration.

3. UTI Background The reason for 1–3% of all GP consultations
About one in three women will have at least one UTI by 24 years of age
About 1 in 2 women will be treated for a symptomatic UTI during their lifetime
The annual incidence of UTI in women increases with age
Escherichia coli account for about 80% of UTIs

4. What is a urinary tract infection (UTI)?
New or worse confusion
Burning
Frequent urination
Fever or shivering
Tummy or back pain
However the second path is critical to the understanding of maybe how we must consider utis in the elderly.
Bacteria in the urine can be normal in older people

5. 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%

6. Using dipsticks What does the Test strip test for?
Bacterial nitrites + WBC =
Negative predictive value 97% CAN rule out UTI
Positive predictive value 60% CANNOT prove UTI

7. What is best practice for UTI?
Do GPs ask for urine dips?
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)

8. Antibiotics are powerful drugs Antibiotics are precious drugs
No dipstick for UTI ?
A positive dipstick is more likely to lead to treatment WHICH MAY NOT BE APPROPRIATE
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

9. 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

10. What is happening locally with UTI?
Data collected from 7 GP practices from a CCG in EoE between Jan-Dec 2016:
44% residents received an antibiotic for UTI in 12 month period
Average of 2 courses per resident treated
Widespread use of dipstick in diagnosis
Poor recording of clinical signs & symptoms
Low number of samples sent for culture
Plan to perform wider data collection for all GPs and Care Homes in the area.

11. Reduction in antibiotic prescribing for UTI in 8 NH over two 6 month periods

12. Prevention is better than cure!
Prevent dehydration = prevent UTIs
Forget to drink
Why?
Longer periods sitting down
Continence problems
Warm environment
Sense of thirst lessens with age
Effects?
Puts strain on kidneys
Bacteria not flushed out of bladder regularly
Makes it harder for body to fight infection
Causes constipation
Increase risk of UTI

13. Tips for carers regarding the prevention of dehydration
Dehydration is the underlying cause of many common conditions including constipation, falls, urinary tract infections, pressure ulcers, malnutrition, incontinence, confusion and Acute Kidney Injury (AKI).
The elderly are more prone to dehydration because:
They may lose the ability to recognise thirst
poor mobility and incontinence may mean a person avoids drinking enough

14. Staying hydrated
Some residents may need further support to stay hydrated. For example:
Choose a cup suitable for the resident – they may prefer to use a straw
Support and encouragement to maintain fluid intake throughout the day
It could be as simple as set drink routines rather than relying on thirst alone
Jelly and other food rich in fluid can be offered to increase fluid intake if the resident doesn’t want to drink
Encourage fluids when giving care at night

15. Prevention is better than cure!
Ensure residents are drinking 1.5 – 2 litres of fluids per day*
*Some residents may have been advised to restrict fluid intake if they have a heart or kidney condition. Discuss with GP or Matron if unsure.

16. Prevention is better than cure!
Standard glass = 200ML
Standard cup = 150ML
Standard jug = 1000ML

17. Spotting dehydration
This urine colour chart will give you an idea of whether a resident is drinking enough. Good means they are drinking enough and dehydrated means the body has lost water and they may need to drink more to make up for the loss.
This chart could be useful although not always a reliable tool in older people because certain conditions and medications may affect urine colour

18. Signs of dehydration Thirst Dark urine Sunken eyes Irritability
Confusion
Cool hands or feet
Low blood pressure
Raised heart rate
Headaches
If a person has AKI they may pass less urine than usual, or pass no urine at all

19. Acute Kidney Injury (AKI)
Acute kidney injury is a sudden and recent reduction in a person’s kidney function. It is often referred to as AKI.
It is identified by blood tests when a raised level of creatinine shows the stage of AKI.
Acute kidney injury can be caused by a number of things such as:
Stress on the kidneys due to illness or infection
Severe dehydration
Side effects of some drugs when you are unwell
Dark / smelly urine often mistaken for sign of a UTI – but more likely to be a sign of dehydration and a chance to act and prevent a UTI
Dark / smelly urine often mistaken for sign of a UTI – but more likely to be a sign of dehydration and a chance to act and prevent a UTI

20. People at higher risk of AKI
Those aged 75 or over People with the following:
Heart failure
Diabetes
Chronic Kidney Disease
Dementia
Acute illness (sickness and diarrhoea)

21. Symptoms of AKI
In the early stages there may be no real symptoms or signs. A blood test is needed to detect it.
However, someone with AKI can deteriorate quickly and suddenly experience any of the following:
Changes to urine output, particularly a major reduction in the amount of urine passed
Changes to urine colour/smell
Nausea, vomiting
Abdominal pains and feeling generally unwell, similar to a hangover
Dehydration or thirst
Confusion and drowsiness

23. Your help and feedback is vital!
Success elsewhere
Across the UK, ‘To Dip Or Not To Dip’ is taking off!
The first ‘To Dip Or Not To Dip’ project was in South-West England:
Reduced antibiotic use in care home residents by over 60%
Reduced emergency admissions for UTI and dehydration by 50%
Your help and feedback is vital!