Evidence base: SIGN guidelines and Cochrane 2008 advise that women with recurrent urinary tract infections (UTIs) consider using cranberry products. Evidence shows that they significantly reduce UTI incidence at 12 months (relative risk, 0.65). The only reported adverse event was an interaction with warfarin. Cochrane 2004 showed that antibiotic prophylaxis for 6 to 12 months reduced the incidence of UTIs compared to controls; however, with more adverse events. This suggests that cranberry juice is preferable to prophylactic antibiotics. SIGN also recommends that men with recurrent UTIs should be referred to urology.
Change strategies: We worked with our urology colleagues to develop a care of the elderly, departmental guide, into the management of recurrent UTIs. This included investigations and the use of cranberry products and prophylactic antibiotics. This was presented, together with first loop audit results in a departmental meeting. The guide was emailed to all medical staff and included in induction material.
Change effects: Pre-intervention, 16% [32/200] of our elderly, inpatient population had recurrent, symptomatic, UTIs, post-intervention, 13% [26/200]. The use of cranberry products increased from 0% to 12% [3/26], in the female population. The use of prophylactic antibiotics fell from 3% to 0%, perhaps because people were appropriately tried on cranberry products first. The referral rate of males to urology increased from 6% to 11%.
Conclusion: We have shown that the incidence and management of recurrent UTIs are a significant problem amongst our elderly, inpatient, population. The reluctance to prescribe prophylactic antibiotics is understandable due to their adverse effects. Our change strategy did improve both the use of cranberry products and referral rate to urology but there is still scope for improvement. Improving the identification of patients with recurrent UTIs, developing clear guidelines on the delivery of cranberry products and improving its availability should also improve compliance with guidelines.