Improving the Diagnosis and Antimicrobial Management of Suspected Urinary Tract Infection in Older Inpatients

Background

Urinary tract infection (UTI) is frequently diagnosed in hospitalised older people, although non-specific presentations such as delirium, falls and confusion may occur without localising urinary symptoms. This can lead to unnecessary antibiotic exposure, delayed microbiological sampling and missed opportunities for antimicrobial de-escalation.

Local problem

An initial audit identified inconsistent assessment of urinary symptoms, delayed culture collection, variable adherence to local antimicrobial guidance and incomplete review of microbiology results. The aim was to improve diagnostic accuracy, timely sampling and guideline-concordant antibiotic prescribing.

Methods

Following the initial audit, a ward-based improvement programme was introduced comprising a UTI diagnostic poster, UTI flyers displayed and distributed across medical wards, and a teaching session for doctors and nurses. A second retrospective audit reviewed 53 patients treated for suspected UTI. Measures included documentation of lower urinary tract symptoms, timing of culture collection and antibiotic administration, empirical antibiotic choice, compliance with local guidance or previous cultures, and review of microbiology results.

Results

The median age was 80 years and 29/53 patients were female. Lower urinary tract symptoms were documented in 18/53 patients (34%). Cultures were obtained within one hour in 5/53 (9%) and within 24 hours in 23/53 (43%). Antibiotics were administered before culture collection in 35/53 (66%). Treatment complied with local guidance or previous culture results in 33/53 (62%); 17/53 (32%) were non-compliant and three records were incomplete. Culture results were reviewed in 37/53 patients (70%). Nitrofurantoin or trimethoprim was used in 7/53 (13%), while broad-spectrum antibiotic use remained common.

Conclusions

The interventions supported improved awareness and microbiology review, but timely sampling, symptom-based diagnosis and antimicrobial selection remained inconsistent. Further actions will include a diagnostic checklist, reinforcement of culture collection before antibiotics where clinically appropriate, and pharmacist-supported antibiotic review and de-escalation.