Introduction

This quality standard covers the management of suspected community‑acquired bacterial urinary tract infection in adults aged 16 years and over. This includes women who are pregnant, people with indwelling catheters and people with other diseases or medical conditions such as diabetes. For more information see the topic overview.

Why this quality standard is needed

Urinary tract infections are caused by the presence and multiplication of microorganisms in the urinary tract. A urinary tract infection can result in several clinical syndromes, including acute and chronic pyelonephritis (infection of the kidney and renal pelvis), cystitis (infection of the bladder), urethritis (infection of the urethra), epididymitis (infection of the epididymis) and prostatitis (infection of the prostate gland). Infection may spread to surrounding tissues (for example, perinephric abscess) or to the bloodstream. A urinary tract infection is defined by a combination of clinical features and the presence of bacteria in the urine. Asymptomatic bacteriuria is the occurrence of bacteria in the urine without causing symptoms. When symptoms occur as a result of bacteria this is referred to as symptomatic bacteriuria.

The incidence of urinary tract infection is highest in young women. Around 10–20% of women will experience a symptomatic urinary tract infection at some time. Most infections in adult men are complicated and related to abnormalities of the urinary tract, although some can occur spontaneously in otherwise healthy young men. Urinary tract infection incidence increases with age for both sexes. It is estimated that 10% of men and 20% of women over the age of 65 years have asymptomatic bacteriuria.

For people with symptoms of urinary tract infection and bacteriuria the main aim of treatment is relief of symptoms. For people who are asymptomatic the main outcome from treatment is prevention of future symptomatic episodes.

In people aged 65 years and over, asymptomatic bacteriuria is common but is not associated with increased morbidity. The diagnosis of urinary tract infection is particularly difficult in older people, who are more likely to have asymptomatic bacteriuria. The prevalence of bacteriuria may be so high that urine culture ceases to be a reliable diagnostic test. Older people in long‑term care (for example, people in care homes) frequently have unnecessary antibiotic treatment for asymptomatic bacteriuria despite clear evidence of adverse effects with no compensating clinical benefit.

The unnecessary use of tests and antibiotic treatment may be minimised by developing simple decision rules, diagnostic guidelines or other educational interventions. Prudent antibiotic prescribing is a key component of the UK's action plans for reducing antimicrobial resistance. Unnecessary antibiotic treatment of asymptomatic bacteriuria is associated with significantly increased risk of clinical adverse events, including Clostridium difficile or methicillin‑resistant Staphylococcus aureus infections, infection with multi‑drug‑resistant gram‑negative organisms including extended‑spectrum beta‑lactamase organisms and carbapenem‑resistant Enterobacteriaceae, and the development of antibiotic‑resistant urinary tract infections. In people with an indwelling urethral catheter, antibiotics do not generally eradicate asymptomatic bacteriuria.

The quality standard is expected to contribute to improvements in the following outcomes:

  • emergency admissions for acute conditions that should not usually require hospital admission

  • health‑related quality of life.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable quality improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

Tables 1 and 2 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition**

Reducing time spent in hospital by people with long‑term conditions

2.3i Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

Alignment with Adult Social Care Outcomes Framework and/or Public Health Outcomes Framework

** Indicator is complementary

Table 2 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

4 Healthcare public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicator

4.13 Health‑related quality of life for older people

Patient experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to urinary tract infections in adults.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services health services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to patients and service users. Quality statements on these aspects of patient experience are not usually included in topic‑specific quality standards. However, recommendations in the development source(s) for quality standards that impact on patient experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for urinary tract infections in adults specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole urinary tract infections in adults care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with urinary tract infections.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality urinary tract infection service are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All healthcare professionals involved in assessing, caring for and treating adults with urinary tract infections should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development source(s) on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with urinary tract infections. If appropriate healthcare professionals should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.