Joint clinic with microbiology to manage recurrent UTIs

Dr Ruth Tyler; Dr Tom Lewis; Dr Susanna Hill

Background

Recurrent and persistent urinary tract infections (UTIs) can be difficult to treat. The National Institute for Health and Care Excellence (NICE) has concluded that there is not enough evidence to guide clinicians in relation to the treatment of recurrent UTIs (1). New research from microbiology has found some patients with persistent lower urinary tract symptoms have chronic infection of the urothelial cells within the bladder (2). In this small study we were able to offer long term antibiotics to selected patients and analyse the results. The study is also an excellent example of a hospital specialist working in the community.

Method

Six patients with recurrent or persistent UTIs were invited to be seen in joint clinic with myself, GP partner Dr Hill and consultant microbiologist Dr Lewis. Patients were presented with two main options for their recurrent or chronic urinary infections. The first was to have a ‘rescue’ script at home in case of infection with an emphasis on self management. The second option was to trial a three month course of full dose antibiotics to clear the presumed ‘bacterial reservoir’ in the bladder. The patients were followed up at three months.

Results

Table 1.

Number of urine infections treated with antibiotics in three months before and after intervention

ruth-tyler1

Patient 1

72 year old lady with recurrent urinary infections with symptoms of dysuria, nocturia and urgency. She had been receiving 100mg od trimethoprim as prophylaxis with some benefit and the urology team were planning to start Cystistat treatment for interstitial cystitis.

With Dr Lewis, it was agreed that the trimethoprim would be stopped and replaced by three months of full dose cefalexin (500mg four times daily); the Cystistat treatment would be postponed.

At three months this lady had stopped the antibiotics due to severe gastro-intestinal side effects and she stated that they were “too strong”. Instead, she had agreed with the urology team that she would take seven days of trimethoprim for acute infections and would stop the long term antibiotic.

Patient 2

61 year old lady with a history of stress incontinence and recurrent UTIs. She had one multi-drug resistant infection but subsequent infections had resolved with first line antibiotics.

The agreed management plan for this lady was a ‘rescue’ script for nitrofurantoin with a sample to be sent to the laboratory. Lifestyle factors were discussed as well as referral for pelvic floor surgery.

At follow up this lady said she would recommend this clinic for other patients and was glad that urinary tract infections are being addressed as “these issues are not talked about enough”. She felt empowered by having the prescription for antibiotics as she could now manage her own symptoms.

Patient 3

63 year old man with a history of diabetes, haematuria and urinary tract infections. He had been taking prophylactic cefalexin (250mg once daily) and was under the urology team.

The management plan was to stop prophylactic antibiotics and treat acute infections with 7 days cefalexin; a prescription for antibiotics was provided. Unfortunately this patient declined follow up.

Patient 4

64 year old lady with persistent urinary tract infections with sweating, malaise, nocturia, dysuria and lower back pain. Unfortunately this lady had been feeling unwell for several years and had been referred to the urology team. She was taking nitrofurantoin 100mg once daily.

The management plan for this lady was to increase the antibiotics to 100mg twice daily for three months along with oestrogen cream and urology investigations; subsequent cystoscopy was normal.

At follow up this lady had a significant improvement in her symptoms. She described feeling more energetic, more alert and her urinary frequency was much improved.

Patient 5

89 year old lady with recurrent episodes of dysuria treated with antibiotics. She had received seven courses of antibiotics in the previous year and was developing multi-drug resistance.

The management plan for this lady was to start long term ciprofloxacin (500mg twice daily) for three to six months to clear the underlying infection. Acute episodes would be treated with a second antibiotic and we agreed a urine sample would need to be sent to the laboratory for analysis.

 At follow up this lady had struggled with the antibiotics due to constipation and joint pains. When she developed further symptoms the antibiotics were restarted and she managed to persevere. She stated that her symptoms “haven’t got any worse” and found her nocturia had improved marginally.

This lady started tolteradine with good effect, although she continued to get occasional infections.

Patient 6

68 year old lady with a history of recurrent and persistent urine infections over the past few years. She had been diagnosed with an atonic bladder with a large residual volume. She had developed multi-drug resistance and had required intravenous antibiotics for recent episodes.

The management plan for this lady was to introduce self catheterisation to ensure the bladder emptied properly, and subsequently could have intravesical gentamicin to clear the infection.

At follow up this lady stated that she found discussing self catheterisation quite upsetting. She had not managed to get to her urology nurse appointment as she was worried about being incontinent. She continued to have accidents and felt this was getting worse; she also enquired about long term catheterisation as a possible solution to her problems.

Discussion and Conclusion

Overall, patients found it helpful to discuss their symptoms with a consultant microbiologist and receiving ‘rescue’ scripts proved to be very popular. The number of acute infections was lower in the three months after the intervention.  Interestingly, the patient who received the greatest benefit from long term antibiotics was the patient with persistent and systemic features of infection.

The benefits to carrying out clinics in a familiar environment (the GP surgery) were that patients felt comfortable and travelling times and costs were reduced. The GP could access past consultation records and consider illness in context of the patient’s life. Some of the subjective changes may be difficult to measure but have been recognised by the RCGP, RCP and King’s fund in the documents referenced below (3, 4, and 5). We gained valuable knowledge from working in collaboration in this study.

References:

(1) NICE quality standard [QS90].  Urinary tract infections in adults. June 2015.

(2) Malone-Lee, James. The spectrum of bacterial colonisation associated with urothelial cells from patients with chronic lower urinary tract symptoms. UCL Medical School, London.

(3) Royal College of General Practice. A Vision for General Practice in the Future NHS. The 2022 GP.

(4) A report from the Future Hospital Commission to the Royal College of Physicians; Future Hospital: Caring for Medical Patients. September 2013.

(5) The King’s Fund. Specialists in out-of hospital settings. October 2014.

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