Urinary tract infection (UTI) is a common clinical presentation and it is seen very frequently in the emergency assessment unit (EAU). Many patients are diagnosed with UTI without clinical evidence of UTI.1,2,3 Previous studies have shown that urine dipstick is not done often enough in acute settings leading to inappropriate usage of antibiotics.4,5 This carries a risk of antibiotic-related complications.6
Almost half of all women report at least one UTI sometime during their lifetime, and after an initial UTI, 20–30% of women experience a recurrence.7
UTIs occur much less frequently in men at all ages. Patients of either sex are more likely to develop a UTI if there is an abnormality of the renal tract or if there has been recent instrumentation of the renal tract.
Antibiotic use changes the vaginal flora and promotes colonisation of the genital tract with e. coli, resulting in subsequent increased risk of UTI.
Other risk factors associated with UTI include:7
• Recent sexual activity
• New sexual partner
• Use of spermicide
• Diabetes
• Presence of catheter
• Institutionalisation
• Pregnancy—possible pregnancy should be sought in women of childbearing age.

Aims and objectives
The aims of the study were to determine the number of patients having urine dipstick that are subsequently diagnosed with a UTI; to establish how long after admission urine dipstick has been done; where the urine dipstick is done (whether in A&E, the EAU or on the ward); also to determine the appropriateness of antibiotics in UTI and whether the antibiotics are changed after culture.

Standards/guidelines and the trust policy
For non pregnant and uncomplicated cases (age >16 years) the recommended first line treatment7,8 was nitrofurantoin 50–100mg four times a day orally for three days. Second line was trimethoprim 200mg twice daily orally for three days if organism susceptible.
In case of treatment failure or recurrent infection, a urine specimen should be taken for culture to guide change of antibiotic. For failed first and second line therapy and patients who are discharged from hospital co-amoxiclav 625mg thrice daily orally for three days is prescribed
In men (adult) first line was nitrofurantoin 50–100mg four times a day orally for seven days. Second line was trimethoprim 200mg twice daily orally for seven days if organism susceptible. For failed first and second line therapy and patients who are discharged from hospital co-amoxiclav 625mg thrice daily orally for seven days, only on consultant or microbiologist advice, is prescribed.7,9
For catheterised patients urine dipstick is not recommended to diagnose urinary tract infection. Start on nitrofurantoin 50mg four times a day. If patient is known to have chronic kidney disease then trimethoprim 200mg twice daily is prescribed.
In cases of complicated urinary tract infections and pyelonephritis (usually gram negative organisms like e.coli and proteus with systemic toxicity) gentamycin intravenous once daily and intravenous tazocin three times daily followed by oral co-amoxiclav for seven days is considered.10 In extended spectrum beta lactamase (ESBL) UTI, ertapenem is first line then oral nitrofurantoin 100mg four times a day for seven days and if systemic sepsis, consider meropenem as first line.

Methodology
Retrospective analysis was made of 100 case notes of patients admitted to EAU with suspected UTI at Russell’s Hall Hospital, Dudley, West Midlands. Subsequently for detailed analysis the data from electronic database was analysed for all the above patients and compiled.

Case scenario
A 78-year-old woman with known heart failure and chronic kidney disease, presented with confusion, nausea and loss of appetite. On examination she was afebrile, observations were stable, systems examination unremarkable except for disorientation to time, place and person. Urine dip was positive for leucocytes and nitrates and culture was sent. She was started on empirical antibiotic trimethoprim as per the local guidelines. The patient did not respond to initial antibiotics. She deteriorated further, became hypotensive, more confused and agitated with sepsis.
After 48 hours her urine culture grew klebsiella oxytoca sensitive to tazocin and augmentin. She was treated with tazocin and improved dramatically and her confusion was completely resolved. She became haemodynamically stable and discharged home subsequently with oral co-amoxiclav.


Recommended treatment
Men
First line treatment is nitrofurantoin 50mg QDS for seven days. Second line is trimethoprim 200mg BD for seven days. If this fails, co-amoxiclav 625mg TDS for seven days.

Women
First line treatment is nitrofurantoin 50mg QDS for three days, second line, trimethoprim 200mg BD for three days, if this fails co-amoxiclav 625mg TDS for three days is prescribed.

Results
The majority of patients (about 85%) were in the older age group and 61% of patients were female. Most of the patients presented with feeling generally unwell, confusion, abdominal pain, fever and dysuria. 55% patients showed signs of pyrexia and remaining patients had suprapubic tenderness.
39% patients had dipsticks done in <12 hours, 29% patients were done on arrival and 15 after 24 hours. Most dipsticks were done in EAU (53%), 30% in the ward with the least done in A&E. Leucocytes and nitrates were positive in more than half of the patients. In urine dip, leucocytes were seen in 23% of patients and nitrates in 18%.
As per recommended guidelines 53% patients started on nitrofurantoin and 15% on trimethoprim. A mid-stream urine (MSU) test was sent in 82% patients, results reviewed in 29/82 and documented in 19 patients only.
40% of patients had positive urine cultures and among them e-coli grew in the majority of the patients (18%), 15% had mixed growth and the remaining patients grew other organisms. 17% patients did not grow any and 15% did not require culture as per the flow-cytometry analysis. Antibiotics were changed in 20 patients. Blood cultures were available in 13 patients only.

Conclusion and recommendations
Dipstick should be done for all patients with suspected UTI. Make sure all patients are sent with MSU and results chased after 48 hours and documented. Antibiotics to be given as per sensitivities and needs to be documented. 

Conflict of interest: None declared.

References
1. Little P, Turner S, Rumsby K, et al. Developing clinical rules to predict urinary tract infection in primary care settings: sensitivity and specificity of near patient tests (dipsticks) and clinical scores. Br J Gen Pract 2006; 56: 606–12
2. Loeb M, Bentley DW, Bradley S, et al. Development of minimum criteria for the initiation of antibiotics in infect. Control Hosp Epidemiology 2001; 22: 120–24
3. Hummers-Pradier E, Koch M, Ohse AM, et al. Antibiotic resistance of urinary pathogens in female general practice patients. Scand J Infect Dis 2005; 37: 256–61
4. Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis. Am J Med 2002; 113(Suppl 1A): 20–28
5. McIsaac WJ, Low DE, Biringer A, et al. The impact of empirical management of acute cystitis on unnecessary antibiotic use. Arch Intern Med 2002; 162: 600–605
6. Grude N, Tveten Y, Jenkins A, Kristiansen BE. Uncomplicated urinary tract infections. Scand J Prim Health Care 2005; 23: 115–19
7. Guideline 88: Management of suspected bacterial urinary tract infection in adults - Full guideline. Scottish Intercollegiate Guidelines Network, 2012
8. Management of suspected bacterial urinary tract infection in adults; Scottish Intercollegiate Guidelines Network - SIGN (updated guidelines 2012)
9. Urinary tract infection (lower) - women - NICE CKS. Clinical Knowledge Summaries, 2009
10. Urinary tract infection (lower) in men—NICE CKS. Clinical Knowledge Summaries, 2010