1. Audit of antibiotics for urinary tract infection prophylaxis in primary care
Angelica Abad, Rachel Trengrove and Naomi Fleming Abstract 181
Background: Women with recurrent urinary tract infections (RUTI) without an indication for referral, should be considered for prophylactic antibiotics when there is unacceptable discomfort or disruption to their lives. UTI prophylaxis  aims to reduce future UTI occurrence, prevent complications and hospital admissions. NICE[1] and Public Health England[2] (PHE) recommended nightly low dose trimethoprim or, nitrofurantoin for a trial of 6 months.
Aims:
Determine the number of patients prescribed UTI prophylaxis from two GP practices.
Determine where prophylaxis was initiated.
Audit the choice of antibiotic against national guidance.[1,2]
Establish acute UTI occurrence in these patients
Determine catheterised patients.
Determine patients at risk of C difficile
Methods: Data was collected from two consenting GP practices in Wellingborough. Patient criteria: aged 18 and over, taking UTI prophylaxis antibiotics for RUTI in the past year.
Exclusions: antibiotics for standby 3 day course, a single post-coital dose, or for peri-operative antibacterial prophylaxis or for prostatitis.
Results: GP1 had 61 (0.36%) and GP2 had 28 (0.22%) patients prescribed UTI prophylaxis antibiotics.
GP1 antibiotic breakdown: nitrofurantoin (45.9%), trimethoprim (27.9%), cefalexin (13.1%), co-amoxiclav (4.9%), pivmecillinam (3.3%), methenamine hippurate (3.3%) and amoxicillin (1.6%).
GP2 antibiotics: trimethoprim (53.5%), nitrofurantoin (25%), co-amoxiclav (10.7%), cefalexin (3.6%), pivmecillinam (3.6%) and ciprofloxacin (3.6%).
Initiation of GP1 patients: 27.9% urologists and 72.1% by GP. GP2 57.1% had urologist initiation, 32.2% GP initiation and 10.7% unclear.
Combined data, GP1 and GP2, 56.2% were treated acutely for UTI. The percentage of patients aged 65 and over was: 70.5% at GP1 and 35.7% at GP2 and of these, 17.0% were on C.diff high risk antibiotics; co-amoxiclav, cefalexin or ciprofloxacin.
Recommendations
1/ Review patients on UTI prophylaxis in light of the new recommendations by PHE[3]. Trimethoprim should now only be used based on sensitivities. 2/ Improve documentation of prophylaxis and set up GP systems to prompt 6 month review. 3/ For patients developing UTI whilst on prophylaxis, guide treatment with culture and sensitivity results. Review prophylaxis based on results. 4/ Review patients at risk of C difficile on higher risk antibiotics.
Discussion
Previous guidelines [1, 2] recommend nitrofurantoin or trimethoprim, with review at 6 months. 75.3% patients were prescribed these.
It was often not clear whether a review of UTI prophylaxis had occurred, yet patients were continued, including those tested for acute UTI with cultures resistant to their current prophylaxis. UTI prophylaxis is not recommended for catheterised patients.[1] , 13.5% patients had catheters. C.diff risks associated with antibiotic use, increase for patients over 65 years and certain antibiotics. 17.0% of older patients were on higher risk antibiotics.
References: [1] NICE. Urinary tract infection (lower) – women (NICE guideline) (accessed 2 December 2016)
[2] Public Health England. Management of Infection Guidance for primary care; 2012.
[3] Public Health England. Management of Infection Guidance for primary care; 2017.