1. Facilitators Notes
This focuses on acute uncomplicated UTI which refers to adult women 14 to 65 years, who have no other complicating factors e.g. catheter, pregnancy, recurrent UTI, renal abnormalities, immunosuppression. It focuses on the correct use of urinalysis, and when alternatives to antibiotics can be considered in this group of women.
Facilitators may find it useful to highlight that within ScRAP there are two other UTI sessions available on complicated (older, catheter-associated, men) and recurrent, should participants wish to discuss these as 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.
Refer to the ScRAP resource pack for the full list of sessions available.

2. Facilitator
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.
See next slide for more detail on the session content and order, including the optional element of process mapping.

3. Facilitator notes
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 is used to introduce the use of a diagnostic algorithm in the assessment of UTI. Using this algorithm allows participants to consider when the use of urinalysis is required and what that means in relation to diagnosis and treatment decisions. The information that follows looks at what needs to be considered when prescribing an antibiotic for uncomplicated UTI.

4. Facilitator notes
Process mapping is useful as it allows everyone in the group to understand each stage in the process, including those which they are not directly involved. 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 (sticky tape might be needed to keep the post-its 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 is their criteria? What questions do they ask? Does it match with the algorithm
For what patients do they use dipstick testing? Is this appropriate? What would they consider a positive dip?
When would they send an MSSU?
What are their treatment choices both for antimicrobials (type and duration) and other alternative treatments?
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 with timescales.

5. Facilitator Notes
PROVIDE COPIES OF THE ALGORITHM (consider printing page 1 and 2 double sided in colour and laminated for ease of use)

6. Facilitator Notes (do not read out)- this case is designed to highlight:
The importance of symptom gathering to identify UTI and exclude differential diagnosis (e.g. chlamydia, thrush)
How you would decide when a urine sample was needed and when to test
How you would use test results to support diagnosis and the influence of this on treatment decision
Suggested Answers
Ask Jen what her symptoms are, the duration of these and the severity (check if any feeling of fever)
Severe symptoms can be defined as those which cause interference with activities of daily living (disruption rather than just inconvenience)
Confirm if she has any vaginal discharge or irritation
Establish her sexual history within the last few days and how many partners she has had in the last 12 months
Confirm what type of contraception she has used
no barrier method increases risk of STI
use of spermicides and diaphragms can increase incidence of UTI
Establish what Jen’s history is in terms of previous UTIs
Confirm not likely to be pregnant (date of last menstrual cycle)
See next slide for what Jen’s signs and symptoms actually are

7. Facilitator Notes
Suggested Answer
If the symptoms had been severe and there was NO vaginal symptoms you could have issued empirical antibiotics without further tests.
However due to the presence of vaginal irritation and the sexual history this makes UTI less likely and she may require genital examination.
The presence of sexually transmitted infection should be considered.

8. Facilitators Notes
To help establish the likelihood of UTI in Jen, a urine sample can be obtained. On visual examination if this is NOT cloudy then this has a 97% negative predictive value (NPV) that this is NOT a UTI and other diagnosis should be considered (note that this is only valid alongside symptoms in female uncomplicated and visual inspection should not be used as a diagnostic tool in isolation or in other patient groups such as the elderly)
In Jen’s case urine is cloudy which merits performing a dipstick
Referring to the algorithm for the urinalysis results - UTI or other diagnosis are equally likely
Urine could be also be sent for microbiological culture to confirm if a UTI is present before deciding if an antibiotic is required (note that this is just where diagnosis is unclear and most women with female uncomplicated will not require culture)
Until the results of the culture are known (if sent) Jen could be given lifestyle advice, and advised to take simple analgesia such as ibuprofen for the dysuria. She is still at work suggesting the symptoms are not severe enough to cause unnecessary disruption to daily living and the symptoms are likely to be self-limiting and improve over the next few days.
We will explore the options around alternatives to immediate antibiotics further in part 2

9. Facilitator notes
Ensure any triage/ screening process the practice has in place would pick the all the relevant symptoms including vaginal and upper UTI. Slide 10 summarises good history taking questions.
In adult female uncomplicated UTI (14-65 yrs) there is a 90% chance it is a UTI if 3 or more symptoms or severe symptoms, and empirical therapy can be issued without urinalysis.
Urinalysis is not therefore indicated in this group of women
Urinalysis is also unnecessary as a follow up ‘test of cure’ unless symptoms persist beyond the expected duration
Unnecessary urinalysis has a cost attached both in terms of time to obtain and test a sample (staff and patient time), and procurement costs for the strips and sample bottles.
Antibiotic choice taking previous use and resistance into account is covered on slide 12 ‘which antibiotic’
Signposting Reference(s) –Additional Diagnosis Information

10. Facilitator Notes
Tests that suggest or prove presence of bacteria in urine may contribute additional information to inform management but rarely have important implications for diagnosis (does not override assessment of the patient symptoms).
Therefore they should be used to supplement decision making where there is uncertainty on the diagnosis rather than be the default on which to make a decision on whether to prescribe an antibiotic.
Note that the visual inspection of the urine is only valid when there are already symptoms and in uncomplicated UTI in non-pregnant adult women under 65 years – not in other patients groups, particularly the elderly where there is a high incidence of bacteriuria.
If there is visible or non-visible haematuria, it is important to send a urine for culture and sensitivity to check if this is a transient bacterial cause. If there is no growth then other causes of haematuria should be investigated e.g. urological cancer. This is based on expert advice in Referral guidelines for suspected cancer in adults and children published by the National Institute for Health and Care Excellence [NICE, 2005], and in a Joint Consensus Statement on the Initial Assessment of Haematuria published by the Renal Association and British Association of Urological Surgeons [Renal Association and British Association of Urological Surgeons, 2008].
Practices should ensure that they refer back to the history when a negative UTI result is received from Microbiology to ensure that there is appropriate follow up/ further investigation in line with the guidance mentioned above. Through the Scottish Patient Safety Programme (SPSP) ‘results handling’, filing of these results assuming no follow up is required has been identified as an area for improvement.
If the group wish to discuss appropriate collection and storing of urine samples information can be found via the following link

11. Facilitator notes
Good history taking is essential to ensuring the correct diagnosis is made, and appropriate testing undertaken.
A GP Practice audit across 5 practices showed low levels of symptom recording (50%), and 40% of patients had no record of direct healthcare professional assessment recorded in the notes.
It is important that if a decision is taken to prescribe an antibiotic that there is a clear rationale behind that and so symptom recording is especially important.
Some practices use questionnaires to support symptom gathering, rather than direct assessment. At the time of writing there was no validated questionnaire available to support this approach.
Where question sheets are used it is suggested that these are prompts to be used within a consultation rather than completed independently by a patient or care staff with no healthcare professional interaction.
Such question sheet assessment prompts should include the aspects listed on this slide to ensure consideration of differential diagnosis (e.g. STI, upper UTI) and assessment of severity.
Public Health England (PHE) have developed a ‘UTI information leaflet’ as part of the TARGET resources which may be of use in consultations

12. Facilitator Notes
Empirical antibiotic choice will be determined by boards guidance which may depend on local resistance patterns
If patients return with an infection it is important to consider what previous resistance and sensitivity patterns were for this patient before issuing further treatment. This is because resistance can persist for up to 12 months in an individual. The slide details how this would work in practice
Where possible cultures should be taken in persistent and recurrent cases 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 empirically for persistent symptoms it is important to give a different antibiotic
Further information (if required) on population resistance levels
It should be remembered that resistance rates in lab samples will overestimate the population rates of resistance.
Only a proportion of the patients treated with an antibiotic (e.g. Trimethoprim) will have samples sent, and of them only a proportion will grow anything.
An observational study done by the POETIC study group (pending publication) found that only 25% of the samples they tested met laboratory criteria for a UTI. Most patients had however been given an antibiotic for suspected UTI. Only 4% of this group had an infection that was resistant to the antibiotic they had been prescribed empirically.
Trimethoprim therefore remains a viable option in uncomplicated female UTI despite resistance rates of 38% (NSS Antibiotic Use & Resistance in Humans 2015).
Antibiotic choice should be considered on a case by case basis though as the slide illustrates
(NB. Further information on resistance if the group wish to discuss it is included in the separate ScRAP session on ‘Resistance and HAI’)
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]. The study found that, after 5 days of antibiotic treatment, symptoms had resolved in 70% of women infected with an organism sensitive to the antibiotic, but in only 24% of women with a resistant isolate. The study also found that 50% of those who reconsulted in the first week had a resistant isolate.

13. Facilitator notes
Discuss practice prescribing data for 3 day usage here if available to see what their 3 day usage is compared to peers
In Scotland in 2015, 55.7% of prescriptions in adult females were for 3 day trimethoprim and 36.8% for 3 day nitrofurantoin1
Good evidence from Cochrane systematic reviews of randomized controlled trials (RCTs) suggests that 3-day courses of antibiotics are almost as effective as longer courses, and adverse effects (including discontinuation) are less likely.2
Signposting evidence/ further information 1.
2. A Cochrane systematic review (search date: August 2003) assessed evidence on effectiveness of different durations of antibacterial treatments in acute, uncomplicated lower urinary tract infection (UTI) in otherwise healthy women 16–65 years of age. The study included 32 trials with 9605 participants, and compared outcomes for 3 days' and 5–10 days' treatment with antibiotic.
*Benefits were either similar or moderately less likely with 3-day treatment.
*There was no significant difference between 3-day and 5 to 10-day antibiotic regimens in terms of:
Symptomatic failure rates at short-term follow up: relative risk (RR) 1.06 (95% CI 0.88 to 1.28, p = 0.52; no statistically significant heterogeneity)
Symptomatic failure rates at long-term follow up: RR 1.09 (95% CI 0.94 to 1.27, p = 0.10; no statistically significant heterogeneity
*3-day treatment was moderately less effective than 5 to 10-day treatment in terms of:
Persistent bacteriuria, short-term: statistically significant only in the subgroup of trials that used the same antibiotic in the two treatment arms: RR 1.37 (95% CI 1.07 to 1.74, p = 0.01; no statistically significant heterogeneity).
Persistent bacteriuria, long-term: RR 1.31 (95% CI 1.08 to 1.60, p = 0.006; no statistically significant heterogeneity).
*Harms were less likely with 3-day treatment. Adverse effects (of any kind): RR 0.83 (95% CI 0.74 to 0.93, p = 0.001). Discontinued therapy: RR 0.51 (95% CI to 0.91, p = 0.02). The authors concluded that longer courses could be considered for women in whom eradication of bacteria in the urine is important (rather than just symptomatic cure).

14. Facilitator Notes
As per slide

15. 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.

16. Facilitator notes
This part looks at the evidence for considering alternative strategies in uncomplicated UTI, such as delayed prescribing, and self-management e.g. simple analgesia for symptomatic relief

17. Facilitators Notes
As per slide
Signposting references
D Mangin, BMJ Editorial: Urinary tract infection in primary care. How doctors deliver care is as influential as the treatment itself BMJ 2010;340:c657
Bleidorn et al, Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection? - Results of a randomized controlled pilot trial, BMC Medicine 2010, 8:30

18. Facilitator Notes
Consider in patients with less severe or limited symptoms.
For a woman with mild symptoms who has normal immunity, normal renal function, and a normal renal tract, treatment can be delayed if she wishes to see if symptoms will resolve without treatment, especially if the urine dipstick test is negative for nitrites and leucocyte esterase (indicating a low probability of a UTI). For all other women start treatment without delay.
Delayed Prescribing in Practice - Watch and Wait
The term ‘delayed’ is often taken to mean giving the patient the prescription at the consultation with instruction on what circumstances they should use.
Unless access to a prescription at a later date (should it be required) would be difficult e.g. over a weekend, some clinicians prefer to adopt a no prescription approach in low risk patients and focus on education and self-management.
This ensures there is no confusion over the messages given, and that the prescriber is adopting a targeted approach and only using delayed as a safety net when there is genuine concern of deterioration.
This helps manage patient future expectations and encourages better risk assessment amongst prescribers.
Evidence from respiratory tract infections suggests it doesn’t matter what method is used to avoid the need for immediate antibiotics and encourage watch and wait – it still results in reduced antibiotic use! (See ScRAP session Targeting antibiotic prescribing for RTI)
Evidence is given on the following slides for these strategies.
Signposting Reference
Butler C et al. Incidence, severity, helpseeking, and management of uncomplicated UTI as population based study BrJGenPract2015: /bjgp15X686965

19. Facilitators Notes
As per slide
Signposting references
Knottnerus et al, Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study, BMC Family Practice 2013, 14:71
Little et al, Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ 2010;340:c

20. Facilitators Notes
As per slide
Signposting references
Leydon et al, Women’s views about management and cause of urinary tract infection: qualitative interview study BMJ 2010;340:c279
Bleidorn et al, Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection? - Results of a randomized controlled pilot trial, BMC Medicine 2010, 8:30
Gaygor I et al.Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial BMJ 2015; 351 doi: (Published 23 December 2015) BMJ 2015;351:h6544

21. Facilitator Notes
Conclusion of Cochrane review: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term.
Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death.
Signposting References
Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care
Little et al, Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study. BMJ 2010;340:b5633

22. Facilitator Notes
Patient information leaflets are a useful way to support information given during a consultation and promote self-management for future episodes
The image shown is a Public Health England developed leaflet to support information provision for Urinary Tract Infection. It is hosted with their TARGET resources

23. 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.

24. Facilitator Notes
Go back to your original map (if available) 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/ group meeting to ensure momentum for implementing change is maintained
Signposting further education
The practice may now wish to undertake the ScRAP sessions on complicated and/ or recurrent UTI
For e-learning see RCGP module ‘Urinary Tract Infection’