Introduction: Urinary tract infections (UTIs) are commonly overdiagnosed in the elderly. The diagnosis of UTI in the elderly can be difficult as there is a high prevalence of asymptomatic bacteriuria, and patients with cognitive impairment or delirium may not be able to volunteer a history of acute urinary symptoms. We defined a UTI as (i) clinical symptoms of a UTI as defined by the Scottish Intercollegiate Guidelines Network or (ii) bacteriuria with evidence of systemic inflammation (temperature >37.5°C, white cell count >11 or C-reactive protein >25).
Change strategies: In November 2011, we performed a snapshot audit of 158 drug charts (from 167 beds) for inpatients on elderly wards to identify antibiotic prescriptions for UTIs. We excluded patients with severe sepsis or those on antibiotics for mixed indications. After the initial audit, we presented our findings at microbiology and geriatric departmental meetings and the grand round. We also shared our findings with our antibiotic pharmacist and the infectious diseases department who routinely audit antibiotic prescriptions. In addition, we delivered regular teaching on the assessment of elderly patients to junior doctors. We repeated our audit in July 2012, examining 156 drug charts from 162 beds.
Change effects: The first audit identified 25 patients on antibiotics for a UTI. Out of 25, 6 (24%) had either clinical or microbiological evidence of a UTI. The second audit identified 16 patients on antibiotics for a UTI. The proportion of patients, 8/16 (50%), appropriately treated increased, as did the proportion of all patients on antibiotics for a UTI.
Conclusion: Like other audits, we identified that UTIs were overdiagnosed. A multifaceted approach resulted in a reduction in inappropriate prescriptions. This is likely to be of benefit in an era of increasing antimicrobial resistance, and significant morbidity from antibiotic side-effects.