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Urinary tract infection in an older patient: a case study and review

Advanced Nurse Practitioner, Primary Care

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Gerri Mortimore

Senior lecturer in advanced practice, department of health and social care, University of Derby

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This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin, by a non-medical prescriber, for a suspected symptomatic uncomplicated urinary tract infection in a patient living in a care home. The focus will be around the consultation and decision-making process of prescribing and the difficulties faced when dealing with frail, uncommunicative patients. This article will explore and critique the evidence-base, local and national guidelines, and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin, a commonly prescribed medication. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with a review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Urinary tract infections are common in older people. Haley Read and Gerri Mortimore describe the decision making process in the case of an older patient with a UTI

One of the growing community healthcare delivery agendas is that of the advanced nurse practitioner (ANP) role to improve access to timely, appropriate assessment and treatment of patients, in an attempt to avoid unnecessary health deterioration and/or hospitalisation ( O'Neill et al, 2021 ). The Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice/Primary Care in England recognises the application of essential skills, including sound consultation and clinical decision making for prescribing appropriate treatment ( Health Education England [HEE], 2020 ). This article will discuss and reflect on a case study involving the prescribing of nitrofurantoin by a ANP for a suspected symptomatic uncomplicated urinary tract infection (UTI), in a patient living in a care home. Focus will be around the consultation and decision-making process of non-medical prescribing and will explore and critique the evidence-base, examining the local and national guidelines and primary research around the pharmacokinetics and pharmacodynamics of nitrofurantoin. Consideration of the legal, ethical and professional issues when prescribing in a non-medical capacity will also be sought, concluding with review of the continuing professional development required to influence future prescribing decisions relating to the case study.

Mrs M, an 87-year-old lady living in a nursing home, was referred to the community ANP by the senior carer. The presenting complaint was reported as dark, cloudy, foul-smelling urine, with new confusion and night-time hallucinations. The carer reported a history of disturbed night sleep, with hallucinations of spiders crawling in bed, followed by agitation, lethargy and poor oral intake the next morning. The SBAR (situation, background, assessment, recommendation) tool was adopted, ensuring structured and relevant communication was obtained ( NHS England and NHS Improvement, 2021 ). The National Institute for Health and Care Excellence ( NICE, 2021 ) recognises that cloudy, foul-smelling urine may indicate UTI. Other symptoms include increased frequency or pressure to pass urine, dysuria, haematuria or dark coloured urine, mild fever, night-time urination, and increased sweats or chills, with lower abdominal/loin pain suggesting severe infection. NICE (2021) highlight that patients with confusion may not report UTI symptoms. This is supported by Gupta and Gupta (2019) , who recognise new confusion as hyper-delirium, which can be attributed to several causative factors including infection, dehydration, constipation and medication, among others.

UTIs are one of the most common infections worldwide ( O'Grady et al, 2019 ). Lajiness and Lajiness (2019) define UTI as a presence of colonising bacteria that cause a multitude of symptoms affecting either the upper or lower urinary tract. NICE (2021) further classifies UTIs as either uncomplicated or complicated, with complicated involving other systemic conditions or pre-existing diseases. Geerts et al (2013) postulate around 30% of females will develop a UTI at least once in their life. The incidence increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point. Further increased prevalence is found in patients who live in a care home, with up to 60% of all infections caused by UTI ( Bardsley, 2017 ).

Greener (2011) reported that symptoms of UTIs are often underestimated by clinicians. A study cited by Greener (2011) found over half of GPs did not record the UTI symptoms that the patient had reported. It is, therefore, essential during the consultation to use open-ended questions, listening to the terminology of the patient or carers to clarify the symptoms and creating an objective history ( Taylor, 2016 ).

In this case, the carer highlighted that Mrs M had been treated for suspected UTI twice in the last 12 months. Greener (2011) , in their literature review of 8 Cochrane review papers and 1 systematic review, which looked at recurrent UTI incidences in general practice, found 48% of women went on to have a further episode within 12 months.

Mrs M's past medical history reviewed via the GP electronic notes included:

• Hypertension
• Diverticular disease
• Basal cell carcinoma of scalp
• Retinal vein occlusion
• Severe frailty
• Fracture of proximal end of femur
• Total left hip replacement
• Previous indwelling urinary catheter
• Chronic kidney disease (CKD) stage 2
• Urinary and faecal incontinence
• And, most recently, vesicovaginal fistula.

Bardsley (2017) identified further UTI risk factors including postmenopausal females, frailty, co-morbidity, incontinence and use of urethral catheterisation. Vesicovaginal fistulas also predispose to recurrent UTIs, due to the increase in urinary incontinence ( Stamatokos et al, 2014 ). Moreover, UTIs are common in older females living in a care home ( Bradley and Sheeran, 2017 ). They can cause severe risks to the patient if left untreated, leading to complications such as pyelonephritis or sepsis ( Ahmed et al, 2018 ).

Mrs M's medication included:

• Paracetamol 1 g as required
• Lactulose 10 ml twice daily
• Docusate 200 mg twice daily
• Epimax cream
• Colecalciferol 400 units daily
• Alendronic acid 70 mg weekly.

She did not take any herbal or over the counter preparations. Her records reported no known drug allergies; however, she was allergic to Elastoplast. A vital part of clinical history involves reviewing current prescribed and non-prescribed medications, herbal remedies and drug allergies, to prevent contraindications or reactions with potential prescribed medication ( Royal Pharmaceutical Society, 2019 ). Several authors, including Malcolm et al (2018) , indicate polypharmacy as a common cause of adverse drug reactions (ADRs), worsening health and affecting a person's quality of life. NICE (2015) only recommends review of patients who are on four or more medications on each new clinical intervention, not taking into account individual drug interactions.

Due to Mrs M's lack of capacity, her social history was obtained via the electronic record and the carer. She moved to the care home 3 years ago, following respite care after her fall and hip replacement. She had never smoked or drank alcohol. Documented family history revealed stroke, ischaemic heart disease and breast cancer. Taylor (2016) reports a good thorough clinical history can equate to 90% of the working diagnosis before examination, potentially reducing unnecessary tests and investigations. This can prove challenging when the patient has confusion. It takes a more investigative approach, gaining access to medical/nursing care notes, and using family or carers to provide further collateral history ( Gupta and Gupta, 2019 ).

As per NICE (2021) guidelines, a physical examination of Mrs M was carried out. On examination it was noted that Mrs M had mild pallor with normal capillary refill time, no signs of peripheral or central cyanosis, and no clinical stigmata to note. Her heart rate was elevated at 112 beats per minute and regular, she had a normal respiration rate of 17 breaths per minute, oxygen saturations (SpO 2 ) were 98% on room air and blood pressure was 116/70 mm/Hg. Her temperature was 37.3oC. According to Doyle and Schortgen (2016) , there is no agreed level of fever; however, it becomes significant when above 38.3oC. Bardsley (2017) adds that older patients do not always present with pyrexia in UTI because of an impaired immune response.

Heart and chest sounds were normal, with no peripheral oedema. The abdomen was non-distended, soft and non-tender on palpation, with no reports of nausea, vomiting, supra-pubic tenderness or loin pain. Loin pain or suprapubic tenderness can indicate pyelonephritis ( Bardsley, 2017 ). Tachycardia, fever, confusion, drowsiness, nausea/vomiting or tachypnoea are strong predictive signs of sepsis ( NICE, 2021 ).

During the consultation, confusion and restlessness were evident. Therefore, it was difficult to ask direct questions to Mrs M regarding pain, nausea and dizziness. Non-verbal cues were considered, as changes in behaviour and restlessness can potentially highlight discomfort or pain ( Swift, 2018 ).

Mrs M's most recent blood tests indicated CKD stage 2, based on an estimated glomerular filtration rate (eGFR) of 82 ml/minute/1.73m 2 . The degree of renal function is vital to establish prior to any prescribing decision, because of the potential increased risk of drug toxicity ( Doogue and Polasek, 2013 ). The agreed level of mild renal impairment is when eGFR is <60 ml/minute/1.73 m 2 , with chronic renal impairment established when eGFR levels are sustained over a 3-month period ( Ahmed et al, 2018 ).

Previous urine samples of Mrs M grew Escherichia coli bacteria, sensitive to nitrofurantoin but resistant to trimethoprim. A consensus of papers, including Lajiness and Lajiness (2019) , highlight the most common pathogen for UTI as E. coli. Fransen et al (2016) indicates that increased use of empirical antibiotics has led to a prevalence of extended spectrum beta lactamase positive (ESBL+) bacteria that are resistant to many current antibiotics. This is not taken into account by the NICE guidelines (2021) ; however, it is discussed in local guidelines ( Barnsley Hospital NHS FT/Rotherham NHS FT, 2022 ).

Mrs M was unable to provide an uncontaminated urine sample due to incontinence. NICE (2021) advocate urine culture as a definitive diagnostic tool for UTIs; however, do not highlight how to objectively obtain this. Bardsley (2017) recognises the benefit of an uncontaminated urinalysis in symptomatic patients, stating that alongside other clinical signs, nitrates and leucocytes strongly predict the possibility of UTI. O'Grady et al (2019) points out that although NICE emphasise urine culture collection, it omits the use of urinalysis as part of the assessment.

Based on Ms M's clinical history and physical examination, a working diagnosis of suspected symptomatic uncomplicated UTI was hypothesised. A decision was made, based on the local antibiotic prescribing guidelines, as well as the NICE (2021) guidelines, to treat empirically with nitrofurantoin modified release (MR), 100 mg twice daily for 3 days, to avoid further health or systemic complications. The use of electronic prescribing was adopted as per local organisational policy and the Royal Pharmaceutical Society (2019) . Electronic prescribing is essential for legibility and sharing of prescribing information. It also acts as an audit on prescribing practices, providing a contemporaneous history for any potential litigation ( Lovatt, 2010 ).

Pharmacokinetics and pharmacodynamics

Lajiness and Lajiness (2019) reflect on the origins of nitrofurantoin back to the 1950s, following high penicillin usage leading to resistance of Gram-negative bacteria. Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010, despite other antibacterial agents being discovered ( Wijma et al, 2020 ). Mckinell et al (2011) highlight that a surge in bacterial resistance brought about interest in nitrofurantoin as a first-line option. Their systematic review of the literature indicated through a cost and efficacy decision analysis that nitrofurantoin was a low resistance and low cost risk; therefore, an effective alternative to trimethoprim or fluoroquinolones. The weakness of this paper is the lack of data on nitrofurantoin cure rates and resistance studies, demonstrating an inability to predict complete superiority of nitrofurantoin over other antibiotics. This could be down to the reduced use of nitrofurantoin treatment at the time.

Fransen et al (2016) reported that minimal pharmacodynamic knowledge of nitrofurantoin exists, despite its strong evidence-based results against most common urinary pathogens, and being around for the last 70 years. Wijma et al (2018) hypothesised this was because of the lack of drug approval requirements in the era when nitrofurantoin was first produced, and the growing incidence of antibiotic resistance. Pharmacokinetics and pharmacodynamics are clinically important to guide effective drug therapy and avoid potential ADRs. Focus on the absorption, distribution, metabolism and excretion (ADME) of nitrofurantoin is needed to evaluate the correct choice for an individual patient, based on a holistic assessment ( Doogue and Polasek, 2013 ).

Nitrofurantoin is structurally made up of 4 carbon and 1 oxygen atoms forming a furan ring, connected to a nitrogroup (–NO 2 ). Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels ( Wijma et al, 2018 ). It works by inhibiting bacterial cell growth, breaking down its strands of DNA ( Komp Lindgren et al, 2015 ). Hoang and Salbu (2016) add that nitrofurantoin causes bacterial flavoproteins to create reactive medians that halt bacterial ribosomal proteins, rendering DNA/RNA cell wall synthesis inactive.

Nitrofurantoin is administered orally via capsules or liquid. Greener (2011) highlights the different formulations, which originally included microcrystalline tablets and now include macro-crystalline capsules. The increased size of crystals was found to slow absorption rates down ( Hoang and Salbu, 2016 ). Nitrofurantoin is predominantly absorbed via the gastro-intestinal tract, enhanced by an acidic environment. It is advised to take nitrofurantoin with food, to slow down gastric emptying ( Wijma et al, 2018 ). The maximum blood concentration of nitrofurantoin is said to be <0.6 mg/l. Lower plasma concentration equates to lower toxicity risk; therefore, nitrofurantoin is favourable over fluoroquinolones ( Komp Lindgren et al, 2015 ). Wijma et al (2020) found a reduced effect on gut flora compared to fluoroquinolones.

Distribution of nitrofurantoin is mainly via the renal medulla, with a renal bioavailability of 38.8–44%; therefore, it is specific for urinary action ( Hoang and Salbu, 2016 ). Haasum et al (2013) highlight the inability for nitrofurantoin to penetrate the prostate where bacteria concentration levels can be present. Therefore, they do not advocate the use of nitrofurantoin to treat males with UTIs, because of the risk of treatment failure and further complications of systemic infection. This did not appear to be addressed by local guidelines.

The metabolism of nitrofurantoin is not completely understood; however, Wijma et al (2018) indicate several potential metabolic antibacterial actions. Around 0.8–1.8% is metabolised into aminofurantoin, with 80.9% other unknown metabolites ( medicines.org, 2022 ). Wijma et al (2020) calls for further study into the metabolism of nitrofurantoin to aid understanding of the pharmacodynamics.

Excretion of nitrofurantoin is predominantly via urine, with a peak time of 4–5 hours, and 27–50% excreted unchanged in urine ( medicines.org, 2022 ). Komp Lindgren et al (2015) equates the fast rates of renal availability and excretion to lower toxicity risks and targeted treatment for UTI pathogens. Wijma et al (2018) found high plasma concentration levels of nitrofurantoin in renal impairment. Singh et al (2015) indicate that nitrofurantoin is mainly eliminated via glomerular filtration; therefore, its impairment presents the potential risks of treatment failure and increased ADRs. Early guidelines stipulated the need to avoid nitrofurantoin in patients with mild renal impairment, indicating the need for an eGFR of >60 ml/min due to this toxicity risk. This was based on several small studies, cited by Hoang and Salbu (2016) , looking at concentration levels rather than focused on patient treatment outcomes.

Primary research by Geerts et al (2013) involving treatment outcomes in a large cohort study, led to guidelines changing the limit to mild to moderate impairment or eGFR >45 ml/min. However, the risk of ADRs, including pulmonary fibrosis and hepatic changes, were increased in renal insufficiency with prolonged use. The study participants had a mean age of 47.8 years; therefore, the study did not indicate the effects on older patients. Singh et al (2015) presented a Canadian study, looking at treatment success with nitrofurantoin in older females, with a mean age of 79 years. It indicated effective treatment despite mild/moderate renal impairment. It did not address the levels of ADRs or hospitalisation. Ahmed et al (2018) conducted a large, UK-based, retrospective cohort study favouring use of empirical nitrofurantoin in the older population with increased risk of UTI-related hospitalisation and mild/moderate renal impairment. It concluded not treating could increase mortality and morbidity. This led to guidelines to support empirical treatment of symptomatic older patients with nitrofurantoin.

Dosing is highly variable between the local and national guidelines. Greener (2011) highlights that product information for the macro-crystalline capsules recommends 50–100 mg 4 times a day for 7 days when treating acute uncomplicated UTI. Local guidelines from Barnsley Hospital NHS FT/Rotherham NHS FT Adult antimicrobial guide (2022) stipulate 50–100 mg 4 times daily for 3 days for women, whereas NICE (2021) recommends a MR version of 100 mg twice daily for 3 days.

In a systematic literature review on the pharmacokinetics of nitrofurantoin, Wijma et al (2018) found that use of a 5–7 day course had similar strong efficacy rates, whereas 3 days did not, potentially causing treatment failure, equating to poor patient outcomes and resistant behaviour. Deresinski (2018) conducted a small, randomised controlled trial involving 377 patients either on nitrofurantoin MR 100 mg three times a day for 5 days or fosfomycin single dose treatment after urinalysis and culture. It looked at response to treatment after 28 days. Nitrofurantoin was found to have a 78% cure rate compared to 50% with fosfomycin. Therefore, these studies directly contradict current NICE and local guidelines on treatment dosing of UTI in women. More robust studies on dosing regimens are therefore required.

Fransen et al (2016) conducted a non-human pharmacodynamics study looking at time of action to treat on 11 strains of common UTI bacteria including two ESBL+. It demonstrated the kill rate for E. coli was 16–24 hours, slower than Enterobacter cloacae (6–8 hours) and Klebsiella pneumoniae (8 hours). The findings also indicated that nitrofurantoin appeared effective against ESBL+. Dosing and urine concentrations were measured, and found that 100 mg every 6 hours kept the urine concentration levels significant enough to reach peak levels. This study directly contradicted the findings of Lindgren et al (2015) , who conducted similar non-human kinetic style kill rate studies, and found nitrofurantoin's dynamic action to be within 6 hours for E. coli. Both studies have limitations in that they did not take into account human immune response effects.

Wijma et al (2020) highlighted inconsistent dosing regimens in their retrospective audit involving 150 patients treated for UTIs across three Australian secondary care facilities. The predominant dosing of nitrofurantoin was 100 mg twice daily for 5 days for women and 7 days for males. Although a small audit-based paper, it creates debate regarding the lack of clarity around the correct dosing, leaving it open to error. It therefore requires primary research into the follow up of cure rates on guideline prescribing regimens. Dose and timing remains an important issue to reduce treatment failure. It indicates the need for bacteria-dependant dosing, which currently NICE (2021) does not discuss.

Haasum et al (2013) found poor adherence to guidelines for choice and dosing in elderly patients in their Swedish register-based large population study. It highlighted high use of trimethoprim in frail older care home residents, despite guidelines recommending nitrofurantoin as first-line. A recent retrospective, observational, quantitative study by Langner et al (2021) involving 44.9 million women treated for a UTI in the USA across primary and secondary care, found an overuse of fluoroquinolones and underuse of nitrofurantoin and trimethoprim, especially by primary care physicians for older Asian and socio-economically deprived patients. Both these studies did not seek a true qualitative rationale for choices of antibiotics; therefore, limiting the findings.

Legal and ethical considerations

NMP regulation of best practice is set by the Royal Pharmaceutical Society framework (2019) , incorporating several acts of law including the medicines act 1968, and medicinal products prescribed by the Nurses Act (1992). As per Nursing Midwifery Council (2021) Code of Conduct and Health Education England (2020), ANPs have a duty of care to patients, ensuring that they work within their area of competence and recognise any limitations, demonstrating accountability for decisions made ( Lovatt, 2010 ).

Empirical treatment of UTIs is debated in the literature. O'Grady et al (2019) summarises that empirical treatment can reduce further UTI complications that can lead to acute health needs and hospitalisation, without increased risk of antibiotic resistance. Greener (2011) states that uncomplicated UTIs can be self-limiting; therefore, not always warranting antibiotic treatment if sound self-care advice is adopted. Chardavoyne and Kasmire (2020) discuss delayed prescribing, involving putting the onus on the patient and carers, which was not advisable in the case of Mrs M. Bradley and Sheeran (2017) found that three quarters of antibiotics in care home residents were prescribed inaccurately, hence recommended a watch and wait approach to treatment in the older care home resident, following implementation of a risk reduction strategy.

Taylor (2016) recommended an individual, holistic approach, incorporating ethical considerations such as choice, level of concordance, understanding and agreement of treatment choice. This can prove difficult in a case such as Mrs M. If a patient is deemed to lack capacity, a decision to act in the patient's best interest should be applied ( Gupta and Gupta, 2019 ). Therefore, understanding a patient's beliefs and values via family or carers should be explored, balancing the needs and possible outcomes. The principle of non-maleficence should be adopted, looking at risks versus benefits on prescribing the antibiotic to the individual patient ( Royal Pharmaceutical Society, 2019 ).

Non-pharmacological advice was provided to the carers to ensure that Mrs M maintained good fluid intake of 2 litres in 24 hours. NICE (2021) advocates the use of written self-care advice leaflets that have been produced to educate patients and/or carers on non-pharmacological actions, supporting recovery and improving outcomes. The use of paracetamol for symptoms of fever and/or pain was also recommended for Mrs M. Prevention strategies proposed by Lajiness and Lajiness (2019) included looking at the benefits of oestrogen cream in post-menopausal women in reducing the incidence of UTIs. Cranberry juice, probiotics and vitamin C ingestion are not supported by any strong evidence base.

There is a duty of care to ensure that follow up of the patient during and after treatment is delivered by the NMP ( Chardavoyne and Kasmire, 2020 ). Clinical safety netting advice was discussed with the carers to monitor Mrs M for any deterioration, and to seek further clinical review urgently. Particular attention to signs of ADRs and sepsis, and the need for 999 response if these occurred, was advocated. A treatment plan was also sent to the GP to ensure sound communication and continuation of safe care ( Taylor, 2016 ).

Professional development issues

The extended role of prescribing brings additional responsibility, with onus on both the NMP and the employer vicariously, to ensure key skills are updated. This is where continued professional development involving research, training and knowledge is sought and applied, using evidence-based, up-to-date practice ( HEE, 2020 ). Adoption of antibiotic stewardship is highlighted by several papers including Lajiness and Lajiness (2019) . They advise nine points to consider, to increase knowledge around the actions and consequences of the drug by the prescriber. Despite no acknowledgment in NICE (2021) guidance, previous results of infections and sensitivities are also proposed as vital in antibiotic stewardship.

The use of decision support tools, proposed by Malcolm et al (2018) , involves an audit approach looking at antibiograms, that highlight local microbiology resistance patterns to aid antibiotic choices, alongside a risk reduction team strategy. Bradley and Sheeran (2017) looked at improving antibiotic use for UTI treatment in a care home in Pennsylvania. They employed a programme of monitoring and educating clinical staff, patients, carers and relatives in evidence-based self-care and clinical assessment skills over a 30-month period. It demonstrated a reduction in inappropriate antibiotic prescribing, and an improvement in monitoring symptoms and self-care practices, creating better patient outcomes. It was evaluated highly by nursing staff, who reported a sense of autonomy and confidence involving team work. Langner et al (2021) calls for further education and feedback to prescribers, involving pharmacists and microbiology data to identify and understand patterns of prescribing.

UTIs can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines. Continued monitoring of nitrofurantoin use requires priority, due to its first-line treatment status internationally, as this may increase reliance and overuse of the drug, with potential for resistant strains of bacteria becoming prevalent.

Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained. The use of competent clinical practice, up-to-date evidence-based knowledge, good communication and understanding of individual patient needs, and concordance are essential to make sound prescribing choices to avoid harm. As well as the prescribing of medications, the education, monitoring and follow-up of the patient and prescribing practices are equally a vital part of the autonomous role of the NMP.

KEY POINTS:

• Urinary tract infections (UTIs) can be misdiagnosed and under- or over-treated, despite the presence of local and national guidelines
• The incidence of UTI increases with age, with those over 65 years of age being five times more likely to develop a UTI at any point
• Nitrofurantoin has been the first-line empirical treatment for UTIs internationally since 2010. Its mode of action is predominantly bacteriostatic, with some bactericidal tendencies in high concentration levels
• Diligent clinical assessment skills and prescribing of appropriate treatment is paramount to ensure risk of serious complications, hospitalisation and mortality are reduced, while quality of life is maintained

CPD REFLECTIVE PRACTICE:

• How can a good clinical history be gained if the patient lacks capacity?
• What factors need to be considered when safety netting in cases like this?
• What non-pharmacological advice would you give to a patient with a urinary tract infection (or their carers)?
• How will this article change your clinical practice?

The Urinary Tract Infection Clinical Case Study Essay

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Introduction

Primary and secondary medical diagnosis, nursing assessment, effects of health status on the patient and patient’s family, support interventions, actual and potential problems.

The patient in the case under consideration, Mr. M., is a 70-year-old male living in an assisted living facility. The patient presents with difficulty ambulating and an unsteady gait resulting in limited physical activity throughout the day. Mr. M. has a history of hypertension controlled with angiotensin-converting enzyme (ACE) inhibitors and hypercholesterolemia. The patient underwent appendectomy and tibia reparation surgery with no noted complications. Currently, Mr. M. is exhibiting memory lapses and has difficulties recalling his family’s names and room numbers in the facility, and often gets lost on the premises. He also shows signs of aggression and disorientation and is incapable of carrying out most activities of daily living.

Patient examination reveals Mr. M. has a body temperature of 37.1 °C, blood pressure of 123/78, heart rate of 93 bpm, respiratory rate of 22 breaths per minute, and oxygen level of 99%. The obtained laboratory results indicate the patient has an increased white blood count of 19.2 (1,000/uL), elevated lymphocyte count of 6700 (cells/uL), and normal protein levels of 7.1 g/dL, 32 U/L AST, and 29 U/L ALT.

The primary diagnosis for Mr. M. is the onset of dementia. The disorder manifests through various cognitive and psychological changes, including memory loss, difficulty with visual and spatial abilities, confusion, disorientation, difficulty handling complex tasks, personality changes, paranoia, and agitation (“Dementia,” 2021). These symptoms are consistent with the ones exhibited by the patient, such as sudden memory loss, mood swings, and inability to perform activities of daily living. The secondary diagnosis is urinary tract infection supported by the elevated white blood count, elevated lymphocyte count, and leukocytes in urine. A urinary tract infection is an infection of any organ within the urinary system, including kidneys, bladder, urethra, and ureters (“Urinary tract infections,” 2020). This infection often presents with cloudy urine, which the patient has. It also can manifest with pain during urination, which the patient denies. However, the patient’s altered mental state should be considered when discussing pain with him.

Further nursing assessments will need to be scheduled to confirm the primary diagnosis of dementia and the secondary diagnosis of urinary tract infection. According to Belleza (2021a), nursing assessments of patients with suspected dementia should include a psychiatric interview and serial assessments of psychiatric status. As acute changes in Mr. M.’s mental status have already been noticed by the staff of the living assisted facility, the next step in the assessment is a psychiatric interview. When assessing the patient for a urinary tract infection, nurses should collect additional information on the frequency, urgency, and hesitancy of urinary patterns and the presence of pain during urination (Belleza, 2021b). A urine culture and a CT scan can be ordered to determine the presence of bacteria in urine and abnormal obstructions in the urinary tract (“Urinary tract infections,” 2020). Thus, during the nursing assessment for dementia and a urinary tract infection, nurses should look for several characteristic abnormalities to confirm the suspected diagnoses.

Dementia and urinary tract infection diagnoses can substantially impact the physical, psychological, and emotional well-being of the patients and their families. Patients with dementia cannot perform self-care tasks and ensure their safety, which can lead to them sustaining physical injuries (“Dementia,” 2021). In addition, cognitive and psychological changes can lead to a patient exhibiting sudden mood changes and developing depression and anxiety (“Dementia,” 2021). Such a diagnosis can also be emotionally challenging to process for the patient’s family, whom he can no longer recognize. Meanwhile, a UTI infection can be physically challenging for the patient due to the pain associated with it. The patient can also experience mood swings, agitation, confusion, and restlessness (Hall, 2021). The diagnosis can present a psychological and emotional burden on the family as they may struggle with seeing their loved ones in a confused or agitated state.

A variety of medication and therapy interventions can be offered to support the patient. Thus, if the dementia diagnosis is confirmed, Mr. M. can be prescribed cholinesterase inhibitors to slow the progression of the disease and antidepressants and anxiolytics to ease restlessness and agitation (Salamon, 2018). In addition, cognitive stimulation and daily orientation therapies can be offered to the patient to help them in their daily routines (Salamon, 2018). The family of the patient can also be offered therapy and professional support to cope with the diagnosis and be trained to help the patient function normally. Antibacterial agents can be offered for the treatment of urinary tract infections. In addition, the patient and his family can be educated on infection prevention measures.

Several actual and potential problems should be considered when discussing this case. Thus, if no treatment is provided for the urinary tract infection, the patient can experience renal failure and urosepsis due to the spread of the infection (Belleza, 2021b). As a patient with suspected dementia, Mr. M. is also at risk of physical injury as he can get confused and lost in a familiar environment. In addition, vitamin deficiency and dehydration pose a potential concern as the patient can forget to eat and drink. Finally, the most urgent problem for the patient will be uncontrolled aggression, which follows as a consequence of disorientation. The patient cannot permanently take sedatives, which will disrupt his rhythm of life and weaken the cognitive functions of the brain. Based on this, it is worth creating an atmosphere and conditions that minimize outbreaks of aggression.

Belleza, M. (2021a). Dementia. Nurseslabs.

Belleza, M. (2021b). Urinary tract infection nursing care and management study guide . Nurseslabs.

Dementia . (2021). Mayo Clinic.

Hall, R. (2021). 3 things you didn’t know about UTIs . Norton Healthcare.

Salamon, M. (2018). Dementia treatments: Medication, therapy, diet, and exercise . WebMD .

Urinary tract infections . (2020). Cleveland Clinic.

• Healthcare: Mrs. Maggie Meriwether Case Study
• Dysuria: Physical Examination and Diagnostics
• Urinary Tract Infections: E. Coli
• Urinary Tract Diseases: Diagnostic Sonography
• Urinary Tract Infections and Dementia Management
• Overactive Bladder: Diagnostic and Treatment
• Pre-diabetes and Urinary Incontinence
• Educating on Urinary Tract Infections in Pregnancy
• Urinary Tract Infection in Pregnant Women
• Pathophysiology of Benign Prostatic Hyperplasia (BPH)
• Chicago (A-D)
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IvyPanda. (2023, March 19). The Urinary Tract Infection Clinical Case Study. https://ivypanda.com/essays/the-urinary-tract-infection-clinical-case-study/

"The Urinary Tract Infection Clinical Case Study." IvyPanda , 19 Mar. 2023, ivypanda.com/essays/the-urinary-tract-infection-clinical-case-study/.

IvyPanda . (2023) 'The Urinary Tract Infection Clinical Case Study'. 19 March.

IvyPanda . 2023. "The Urinary Tract Infection Clinical Case Study." March 19, 2023. https://ivypanda.com/essays/the-urinary-tract-infection-clinical-case-study/.

1. IvyPanda . "The Urinary Tract Infection Clinical Case Study." March 19, 2023. https://ivypanda.com/essays/the-urinary-tract-infection-clinical-case-study/.

Bibliography

IvyPanda . "The Urinary Tract Infection Clinical Case Study." March 19, 2023. https://ivypanda.com/essays/the-urinary-tract-infection-clinical-case-study/.

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Urinary Tract Infection Case Study

• Jordan Bittengle
• Kellie Berry
• Kristina Hickman
• Leslie Starkey

Our rationale for choosing this condition:

We chose urinary tract infection as our case study because we all have experience taking care of patients that have had urinary tract infections. Our group thought this was a good topic because we know that moving forward in our careers, we will take part in treating patients with urinary tract infections no matter what setting we work in.

https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447

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Abernethy J, Guy R, Sheridan EA Epidemiology of Escherichia coli bacteraemia in England: results of an enhanced sentinel surveillance programme. J Hosp Infect. 2017; 95:(4)365-375 https://doi.org/10.1016/j.jhin.2016.12.008

Allison R, McNulty C Urinary tract infections: when is it appropriate to prescribe an antibiotic?. Guidelines in practice. 2019; https://bit.ly/2Nig5DS

Anderson C Exploring the role of advanced nurse practitioners in leadership. Nurs Stand. 2018; 33:(2)29-33 https://doi.org/10.7748/ns.2018.e11044

Balogun SA, Philbrick JT Delirium, a symptom of UTI in the elderly: fact or fable? a systematic review. Can Geriatr J. 2014; 17:(1)22-26 https://doi.org/10.5770/cgj.17.90

Urinary tract infections in women: aetiology. 2020; https://bestpractice.bmj.com/topics/en-gb/3000120

Bonkat G, Bartoletti R, Bruyère F EAU Urological Infections Guideline. 2020; https://uroweb.org/guideline/urological-infections/#1

Butler CC, Hawking MKD, Quigley A, McNulty CAM Incidence, severity, help seeking, and management of uncomplicated urinary tract infection: a population-based survey. Br J Gen Pract. 2015; 65:(639)e702-e707 https://doi.org/10.3399/bjgp15x686965

Cove-Smith A, Almond MK Management of urinary tract infections in the elderly. Trends in Urology Gynaecology and Sexual Health. 2007; 12:31-34 https://doi.org/10.1002/tre.33

Chu CM, Lowder JL Diagnosis and treatment of urinary tract infections across age groups. Am J Obstet Gynecol. 2018; 219:(1)40-51 https://doi.org/10.1016/j.ajog.2017.12.231

Gau JT, Shibeshi MR, Lu IJ Interexpert agreement on diagnosis of bacteriuria and urinary tract infection in hospitalized older adults. J Am Osteopath Assoc. 2009; 109:(4)220-226

Gharbi M, Drysdale J, Lishman H Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study. BMJ. 2019; 364 https://doi.org/10.1136/bmj.l525

2017; https://bit.ly/3qODbQi

British National Formulary online. 2021; https://bnf.nice.org.uk/

Kalra O, Raizada A Approach to a patient with urosepsis. J Glob Infect Dis. 2009; 1:(1)57-63 https://doi.org/10.4103/0974-777x.52984

Latour K, Plüddemann A, Thompson M Diagnostic technology: alternative sampling methods for collection of urine specimens in older adults. Family Medicine and Community Health. 2013; 1:(2)43-49

Lutters M, Vogt-Ferrier NB Antibiotic duration for treating uncomplicated, symptomatic lower urinary tract infections in elderly women. Cochrane Database Syst Rev. 2008; 3 https://doi.org/10.1002/14651858.cd001535.pub2

MacLullich A, Ryan T, Cash H 4AT rapid clinical test for delirium (version 1.2). 2014; https://www.the4at.com/

Mayne S, Bowden A, Sundvall PD, Gunnarsson R The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing—a systematic literature review. BMC Geriatr. 2019; 19:(1) https://doi.org/10.1186/s12877-019-1049-7

Michels TC, Sands JE Dysuria: evaluation and differential diagnosis in adults. Am Fam Physician. 2015; 92:(9)778-786

Urinary incontinence in neurological disease: assessment and management. Clinical guideline 148. 2012; https://www.nice.org.uk/guidance/cg148/

Urinary tract infections in adults: Quality Standard 90. 2015; https://www.nice.org.uk/guidance/qs90

Sepsis: risk stratification tools. 2017; https://www.nice.org.uk/guidance/ng51/resources/

Urinary tract infection (lower): antimicrobial prescribing. NICE guideline 109. 2018a; https://www.nice.org.uk/guidance/ng109

Pyelonephritis (acute): antimicrobial prescribing. NICE guideline 111. 2018b; https://www.nice.org.uk/guidance/ng111

Urinary tract infection (catheter-associated): antimicrobial prescribing. NICE guideline 113. 2018c; https://www.nice.org.uk/guidance/ng113

Clinical Knowledge Summaries: Urinary tract infection (lower) - women. 2020a; https://cks.nice.org.uk/urinary-tract-infection-lower-women#!topicSummary

Clinical Knowledge Summaries: Pyelonephritis - Acute. 2020b; https://cks.nice.org.uk/pyelonephritis-acute#!topicSummary

Suspected cancer: recognition and referral. NICE guideline 12. 2021; https://www.nice.org.uk/guidance/ng12

Summary of antimicrobial prescribing guidance –managing common infections. 2020; https://bit.ly/2OZ0OrZ

Sepsis guidance implementation advice for adults. 2017; https://www.england.nhs.uk/wp-content/uploads/2017/09/sepsis-guidance-implementation-advice-for-adults.pdf

Point-of-care testing for urinary tract infections. 2016; https://bit.ly/3tmUHwA

Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005; 40:(5)643-654 https://doi.org/org/10.1086/427507

Ninan S, Walton C, Barlow G Investigation of suspected urinary tract infection in older people. BMJ. 2014; 349 https://doi.org/org/10.1136/bmj.g4070

The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018; https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf

Perrotta C, Aznar M, Mejia R, Albert X, Ng CW Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev. 2008; 2 https://doi.org/10.1002/14651858.cd005131.pub2

Philips H, Huibers L, Holm Hansen E Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries. Qual Prim Care. 2014; 22:(4)221-231

Portman DJ, Gass MLS Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Maturitas. 2014; 79:(3)349-354 https://doi.org/10.1016/j.maturitas.2014.07.013

UK Standards for microbiology investigations: investigation of urine. 2019; https://bit.ly/3eDm1ml

English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR): 2019–2020. 2020a; https://bit.ly/30UWNaN

Diagnosis of urinary tract infections: Quick reference tool for primary care for consultation and local adaptation. 2020b; https://bit.ly/3tmXOEV

Annual epidemiological commentary: Gram-negative bacteraemia, MRSA bacteraemia, MSSA bacteraemia and C. difficile infections, up to and including financial year April 2019 to March 2020. 2020c; https://bit.ly/2OR0yLM

30-day all-cause fatality subsequent to MRSA, MSSA and Gram-negative bacteraemia and C. difficile infections, April 2019 to March 2020. 2021; https://bit.ly/3lsvGgE

Rowe TA, Juthani-Mehta M Urinary tract infection in older adults. Aging Health. 2013; 9:(5)519-528 https://doi.org/10.1016/j.idc.2013.10.004

National Early Warning Score (NEWS) 2: Standardising the assessment of acute-illness severity in the NHS.London: RCP; 2017

Management of suspected bacterial urinary tract infection in adults: a national clinical guideline. 2012; https://bit.ly/3eG6XUV

Risk reduction and management of delirium. SIGN 157. 2019. https://bit.ly/3bPcgQ5

Thornton HV, Hammond A, Hay AD Urosepsis: a growing and preventable problem?. Br J Gen Pract. 2018; 68:(675)493-494 https://doi.org/10.3399/bjgp18x699317

The Sepsis Manual. 2019; https://bit.ly/3rXaimn

The management of urinary tract infections in older patients within an urgent care out-of-hours setting

Justine Dexter

Advanced Nurse Practitioner, Urgent Care, South Derbyshire, DHU Health Care

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Gerri Mortimore

Lecturer, Faculty of Education Health and Sciences, University of Derby

View articles · Email Gerri

This article critically analyses the prevalence, assessment and management of urinary tract infections (UTIs) in patients over the age of 65, in an urgent care out-of-hours service in order to enhance care. It is undertaken from the perspective of working as an Advanced Nurse Practitioner (ANP). A synopsis of UTI is presented, examining the epidemiology and aetiology. The process of assessment, diagnosis and management of UTI in older people is appraised based on current evidence. Difficulties associated with the recognition of UTI in elderly are evaluated. Finally, recommendations are made for the improvement of future practice as an ANP.

Urinary tract infections (UTIs) are among the most frequent bacterial infections seen within primary care ( National Institute for Health and Care Excellence (NICE), 2020a ). They are caused by the presence of multiplying microorganisms in the urinary tract with infection being determined by a combination of bacteria in the urine plus clinical features ( NICE, 2015 ). It is estimated that more than 92 million people are affected worldwide and among older people, UTI is a substantial cause of mortality ( NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative, 2016 ). It is estimated that 1-3% of primary care attendances are due to UTI-related symptoms and they comprise the main reason for 13.7% of antibiotic prescribing ( NIHR Community Healthcare Medtech and In Vitro Diagnostics Cooperative, 2016 ). The prevalence is approximately 20% in women aged over 65, compared with 11% in the overall population ( Chu and Lowder, 2018 ). However, both genders are at risk of UTI in older age, with a male-to-female ratio of 1:2 ( Cove-Smith and Almond, 2007 ). The risk increases substantially in patients over the age of 85 ( Rowe and Juthani-Mehta, 2013 ).

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Uncomplicated urinary tract infections.

Michael J. Bono ; Stephen W. Leslie ; Wanda C. Reygaert .

Affiliations

Last Update: November 13, 2023 .

• Continuing Education Activity

Uncomplicated urinary tract infections (UTIs) are among the most common bacterial infections encountered in clinical practice. They primarily affect the lower urinary tract, involving the bladder and associated structures. Unlike complicated UTIs, uncomplicated cases occur in otherwise healthy individuals with no structural abnormalities of the urinary tract or significant comorbidities. Although some cases may resolve spontaneously, many patients seek therapy for symptom relief and to prevent potential complications. Prompt and accurate diagnosis of uncomplicated UTIs is essential for timely and appropriate management. Preventative strategies to reduce UTIs are critical in reducing the burden on health care resources. By understanding the key aspects of uncomplicated UTIs, health care professionals can optimize patient care and contribute to better overall outcomes. This article reviews uncomplicated UTIs, including their clinical presentation, diagnosis, and treatment approaches, and highlights the role of the interprofessional team in collaborating to provide coordinated and comprehensive care. 

• Screen patients effectively for UTI symptoms, risk factors, and relevant medical history to prompt early diagnosis.
• Select appropriate diagnostic tests and interpret results accurately to confirm UTIs and guide treatment decisions.
• Implement evidence-based guidelines, treatment protocols, and preventative strategies to optimize patient outcomes.
• Collaborate with the interprofessional team to ensure comprehensive care for patients with uncomplicated UTIs.
• Introduction

An uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. Patients with uncomplicated UTIs have no structural abnormality of the urinary tract and no comorbidities such as diabetes, an immunocompromised state, recent urologic surgery, or pregnancy. An uncomplicated UTI is also known as cystitis or a lower tract UTI.

Bacteriuria or pyuria alone without symptoms does not constitute a UTI. Typical UTI symptoms include urinary frequency, urgency, suprapubic discomfort, and dysuria. While very common in women, UTIs are uncommon in circumcised males. When UTIs occur in circumcised males, by definition, they are generally considered complicated UTIs. [1]

Many uncomplicated UTIs will resolve spontaneously without treatment, but patients often seek therapy for symptom relief. Therapy aims to prevent infection from spreading to the kidneys or progressing into an upper tract disorder such as pyelonephritis, which can destroy delicate structures in the nephrons and eventually lead to hypertension. [2] [3] [4]

The diagnosis of a UTI is made from the clinical history and urinalysis with confirmation by a urine culture. Proper urine sample collection is essential for adequate evaluation and culture.

Complicated urinary tract infections and recurrent UTIs are covered in separate articles. See the companion StatPearls reference articles on "Complicated Urinary Tract Infections" and "Recurrent Urinary Tract Infections." [1] [5]

Pathogenic bacteria ascend from the perineum and rectum to the periurethral area, predisposing women to UTIs. Women also have much shorter urethras than men, further contributing to their increased susceptibility. Blood-borne bacteria cause very few uncomplicated UTIs.

Escherichia coli  causes the vast majority of UTIs, followed by  Klebsiella,  but other organisms of importance include  Proteus ,  Enterobacter , and  Enterococcus . [6] [7]

A significant risk factor for UTIs is the use of a urinary catheter. Manipulation of the urethra is also a risk factor. UTIs are very common after kidney transplants, with the main factors being immunosuppressive drugs and vesicoureteral reflux. Additional risk factors include the use of antibiotics with increasingly resistant bacterial strains and diabetes mellitus.

Other risk factors include:  [8] [9] [10] [11]

• Abnormal urination (e.g., incomplete emptying, neurogenic bladder)
• Abnormal urinary tract anatomy or function
• Antibiotic use and increasing bacterial resistance
• Dehydration
• First UTI before 15 years of age
• Frequent pelvic examinations
• Incomplete bladder emptying
• Immune system suppression or inadequacy
• Irritable bowel syndrome 
• Mother with a history of multiple UTIs
• New or multiple sexual partners
• Poor personal hygiene
• Sexual intercourse
• Urinary tract calculi
• Use of spermicides and diaphragms 
• Epidemiology
• UTIs occur at least 4 times more frequently in females than males.
• Forty percent of women in the United States will develop a UTI during their lifetime.
• About 10% of women will get a UTI yearly.
• Recurrences are common, with nearly half of patients getting a second infection within a year.
• In women, UTIs usually occur between the ages of 16 to 35 years. [12] [13]
• Pathophysiology

An uncomplicated UTI usually solely involves the bladder. Most organisms causing a UTI are enteric coliforms that typically inhabit the periurethral vaginal introitus. When these organisms ascend the urethra into the bladder, they invade the bladder mucosal wall, resulting in an inflammatory reaction called cystitis. Sexual intercourse is a common cause of a UTI as it promotes the passage and inoculation of bacteria into the bladder. [14]

Urine is naturally antimicrobial. Factors making it unfavorable for bacterial growth include a pH <5, high urea levels, hyperosmolality, and the presence of organic acids, proteins, and nitrites. [15] [16]  Urinary proteins, such as Tamm-Horsfall glycoproteins, nitrites, and urea, are all bacterial growth inhibitors. [15] [16] [17] [18] [19]  Frequent urination and high urinary volumes also decrease the risk of UTIs. The bladder wall lining is covered by a layer of mucus, which acts as a mechanical barrier to bacterial infiltration and invasion. Any defect or injury of this mucosal layer is considered a predisposing factor to a UTI and recurrent infections. [20]  

Urothelial cells also act to protect the bladder from infection. They can produce many antimicrobial peptides and pro-inflammatory cytokines, such as IL-1, IL-6, and IL-8. [21]  They can encapsulate bacteria in fusiform vesicles, and when highly infected with bacteria, the superficial urothelial layer can be shed, substantially reducing the bacterial count. [21] [22]  Premenopausal women have large concentrations of lactobacilli in the vagina and an acidic vaginal pH, preventing colonization with uropathogens. Antibiotic use can eliminate this protective effect. [23]

Bacteria that cause UTIs tend to have adhesins on their surface, allowing organisms to attach to the urothelial mucosal surface. [24]  Pathogenic bacteria develop mechanisms to survive hyperosmolality, and many can break down urea into alkaline ammonia to increase urinary pH. [21]  In addition, the short female urethra allows uropathogens to invade the bladder and lower urinary tract. [1]  Glycosuria can increase the risk of UTIs in diabetics, and recurrent infections can delay the recovery of the superficial urothelium and protective mucus layer. [25]

• History and Physical

Symptoms of uncomplicated UTIs are typically pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitancy), sudden onset of the need to urinate (urgency), suprapubic pain or discomfort, bladder spasms, and blood in the urine (hematuria). Usually, patients with uncomplicated UTIs do not have fever, chills, nausea, vomiting, or back/flank pain, which are more typical of renal involvement or pyelonephritis. [8]  Patients with neurological diseases, such as multiple sclerosis, may present with atypical symptoms, such as an acute exacerbation of neurological symptoms.

Clinical symptoms can overlap. Sometimes, it can be hard to distinguish an uncomplicated UTI from a renal infection or other serious infection. When in doubt, it is generally best to treat aggressively for possible upper urinary tract disease.

Information on prior antibiotic use and previous UTIs should be obtained.

Findings on physical examination are typically negative in a patient with an uncomplicated UTI, although suprapubic tenderness may be found in 10% to 20% of cases. Patients with recurrent UTIs, unexplained incontinence, or suspected organ prolapse should have a pelvic exam. [8]  

A UTI diagnosis is a combination of signs, symptoms, and urinalysis results confirmed with a urine culture. Be wary of a diagnosis based primarily on urinalysis or culture results in asymptomatic patients. If there are no clinical signs or symptoms, it is most commonly not a UTI.

Odoriferous or cloudy urine may often be associated with UTIs and bacteriuria. Still, these findings alone do not constitute a UTI requiring antibiotic treatment unless the patient exhibits other signs or symptoms. [26]  Increased hydration and a careful review of contributing dietary and drug factors are indicated in these situations.

Unusual urinary cloudiness (turbidity) and odor are caused or easily affected by the following:

• Amorphous phosphates
• Foods (see below)
• Hormonal changes (eg, pregnancy)
• Hydration status
• Liver failure 
• Medications (sulfonylurea)
• Renal failure
• Sexually transmitted infections
• Trimethylaminuria
• Vaginal infections
• Voiding dysfunction unrelated to infection

Foods that can cause urinary odor include:

• Brussels sprouts
• Fish (salmon)
• Sulfur-containing foods

Special Patient Populations

Older and/or Frail Patients

In older patients, symptoms such as changes in mental status or behavior may be present. [26]  There may be unexplained lethargy, disorganized speech, or altered perception. [27]  The most reliable indicators in older and/or frail patients are a change in mental status, abnormal urinalysis (pyuria and bacteriuria), and dysuria. [26]  Additional symptoms may include nocturia, incontinence, or a general sense of not feeling well with no specific urinary symptoms. [28]

Spinal Cord-injured Patients

Spinal cord-injured patients with paralysis may present with the following:

• Autonomic dysreflexia presents with severe hypertension and headache in spinal cord injured patients (T-6 and above). [29]
• Cloudy, foul-smelling urine 
• Increased or a new presentation of spasticity
• Unexplained fatigue

Patients with Permanent Indwelling Foley Catheters or Suprapubic Tubes  

Patients with permanent indwelling Foley catheters or suprapubic tubes   may have vague signs and symptoms, including an elevated leukocyte count and low-grade fever. Most patients with catheters will have pyuria and high urinary bacterial colony counts. This is not an actual urinary tract infection and should not be treated unless there are systemic signs or symptoms of pain, spasms, hematuria, or other abnormal bladder activity.

Urine Specimen Collection

A properly collected, clean urinalysis specimen is critical to the work-up. Patients should wash their hands before obtaining a sample. Midstream voided clean catch specimens are very accurate and preferred in non-obese women and men, assuming the patient follows the correct technique. Most obese women cannot give a clean, uncontaminated specimen. Epithelial cells in the urinalysis mean the urine sample was exposed to the genital skin surface and did not come directly from the urethra. Obtaining a sample with very few epithelial cells may require a urethral catheterization. The risk of a UTI in uninfected women from a straight urethral catheterization of the bladder is approximately 1%.

Men should wipe the glans, start the urine stream to clean the urethra, and obtain a midstream sample. In young children and patients with spinal cord injuries, suprapubic aspiration may be needed to collect a proper urine specimen. The Foley should be changed in patients with catheters, and the specimen should be collected from there. Never perform a urine culture or urinalysis from a sample taken directly from a urinary drainage bag. If necessary, keep the new Foley catheter clamped for a few minutes to allow for enough urine to collect to provide an adequate sample.

Urine should be sent to the lab immediately or refrigerated because bacteria proliferate when the sample is left at room temperature, causing an overestimation of the bacterial count and severity. [30] [31]

Do not base the diagnosis of a UTI solely upon visual inspection of the urine. Cloudy urine can be aseptic; the turbidity can come from protein or calcium phosphate debris in the sample and not necessarily from an infection. On the contrary, crystal-clear urine can be grossly infected. All urines should undergo dipstick testing, which can be done in the clinic or at the bedside.

The most helpful dipstick values diagnostically are pH, nitrites, leukocyte esterase, and blood. Remember that in patients with symptoms of a UTI, a negative dipstick result does not rule out the UTI, but positive findings can suggest the diagnosis. Look for the presence of bacteria and/or white blood cells (WBC) in the urine on microscopic urinalysis.  

• Normal urine pH is slightly acidic, with usual values of 5.5 to 7.5, but the normal range is 4.5 to 8.0. A urine pH of 8.5 to 9.0 indicates a urea-splitting organism, such as  Proteus , Klebsiella , or Ureaplasma urealyticum.  An alkaline urine pH can signify struvite kidney stones, also known as "infection stones." [32]
• The nitrate test is the most accurate dipstick test for a UTI because bacteria must be present in the urine to convert nitrates to nitrites. This process takes 6 hours and is why urologists often request the first-morning urine for testing, particularly in males. The overall specificity of this test is >90%. [33] [34] This test is a direct confirmation of bacteria in the urine, which is a UTI by definition in patients with symptoms. Several bacteria do not convert nitrates to nitrites, but those are usually involved in complicated UTIs, such as  Enterococcus, Pseudomonas , and Acinetobacter . The overall sensitivity of the nitrite urinary dipstick test is 19% to 48%, while its specificity is 92% to 100%. [35]
• Leukocyte esterase identifies the presence of WBCs in the urine. The WBCs release leukocyte esterase, presumably in response to bacteria in the urine. Leukocyte esterase can detect WBCs in the urine, but this can occur for other reasons, like inflammatory disorders and vaginal infections. Its reported sensitivity is 62% to 98%, with a specificity of 55% to 96%. [11]  Despite this, leukocyte esterase is generally not considered as reliable a UTI indicator as nitrites. 
• Hematuria can be a helpful finding because bacterial infections of the transitional cell lining of the bladder often cause some bleeding. This finding helps distinguish a UTI from vaginitis and urethritis, which do not cause blood in the urine.

The predictive values of nitrite, leucocyte esterase, and blood on a dipstick for diagnosing a UTI have been measured. The finding of urinary nitrites was more significant than leukocyte esterase, which was superior to hematuria. Both positive nitrites and leukocyte esterase have been found to have a high positive predictive value (PPV) of 85% and a 92% negative predictive value (NPV). [36]  The combination of all three (nitrites, leukocyte esterase, and hematuria) has also been found to be useful. [37]  Dysuria and new onset nocturia/frequency were also associated with UTIs.

In many labs, the presence of nitrites or leukocyte esterase will automatically trigger a microscopic evaluation of the urine for bacteria, WBCs, and RBCs and/or urine culture. On microscopy, there should be no visible bacteria in uninfected urine, so any bacteria visible on a Gram-stained urine specimen under high-field microscopy is highly correlated to bacteriuria and UTIs. A properly collected urine sample with >10 WBC/HPF is abnormal and highly suggestive of a UTI in symptomatic patients.

Urine Culture

Urine cultures are not usually required in uncomplicated UTIs but are still recommended by some due to increasing antibiotic resistance patterns and to help differentiate recurrent from relapsing infections. [8]  Cultures also help guide treatment if the patient fails to improve on initial empiric therapy. Urine should be cultured in all men, patients with diabetes mellitus, immunosuppressed individuals, and pregnant women. [8] Classic teaching for diagnosing a UTI sets the standard for culturing infected urine at >100,000 colony-forming units per milliliter (CFU/mL).

Recent literature and the American Urological Association Core Curriculum state that a patient with symptoms and a urine culture showing >1,000 CFU/mL should be diagnosed with a UTI. [5] Twenty to forty percent of women with UTIs will have ≤10 000 CFU/mL on urine culture. [5] [38]  From a practical clinical standpoint, a single organism in a symptomatic patient of 1,000 or more CFU/mL is now generally considered diagnostic for a UTI. [5] [38]

Urine cultures rarely help in the emergency department, except with recurrent UTIs, but can make subsequent treatment easier if patients do not respond to the initial antibiotic prescribed. [39]  While a single, uncomplicated UTI may not require a culture, the clinician otherwise has no objective evidence to guide therapy if the original treatment fails. Therefore, many experts recommend that all patients treated for a presumed UTI should have a urine culture, which can be extremely helpful in certain situations. [8] . 

Cystoscopy and urinary tract imaging are generally not recommended for uncomplicated UTIs as they are rarely helpful. [39]  Imaging may be beneficial for relapsing infections.

• Treatment / Management

Asymptomatic bacteriuria is quite common and requires no treatment, except in pregnant women, those who are immunosuppressed, have had a transplant, or recently underwent a urologic surgical procedure. Significant bacteriuria should also be treated before invasive urologic surgical procedures.

Management of Uncomplicated UTIs

Antibiotic treatment has varied historically from 3 days to 6 weeks. There are excellent cure rates with "mini-dose therapy," which involves just 3 days of treatment.

E. coli resistance to common antimicrobials varies in different areas of the country. Another drug should be chosen if the resistance rate is >50% to any particular antibiotic.

First-line agents for uncomplicated UTIs include nitrofurantoin, sulfamethoxazole/trimethoprim,  fosfomycin, and first-generation cephalosporins. Outside the US, pivmecillinam is also considered first-line therapy.

• Nitrofurantoin is perhaps the preferred choice for uncomplicated UTIs, but it is bacteriostatic, not bacteriocidal, and must be used for 5 to 7 days. It has several mechanisms of action that affect bacteria, so resistance is relatively uncommon. It is only effective in the lower urinary tract due to poor tissue concentrations and cannot be used for presumed or possible pyelonephritis. It is the preferred drug for low-dose long-term prophylaxis in patients with recurrent UTIs. [5]
• Sulfamethoxazole/trimethoprim for 3 days is good mini-dose therapy, but resistance rates are high in many areas. It should not be used if local bacterial resistance is >20% or in patients with a sulfa allergy. [40] [41]  Sulfamethoxazole/trimethoprim is generally the alternate drug of choice for long-term prophylaxis in patients with recurrent UTIs.
• Fosfomycin is FDA-approved as a single-dose therapy for uncomplicated UTIs. [42]  It may be effective when there is significant resistance to other antimicrobials. [43] A single dose will provide therapeutic urinary concentrations for 2 to 4 days and is comparable to 7- to 10-day therapy with other agents. [42] [44]  Adjunctive therapy with phenazopyridine for several days may provide additional symptomatic relief. [45]
• First-generation cephalosporins are good choices for mini-dose (3-day) therapy but should not be overused to avoid resistance.
• Fluoroquinolones have high resistance but are preferred for pyelonephritis and prostatitis due to their high tissue penetration levels, especially in the prostate. For this reason, fluoroquinolones are not preferred for uncomplicated UTIs but may be used when other agents are not acceptable. [46] [47] [48] Fluoroquinolones and nitrofurantoin are mutually antagonistic and should not be used together. Recent precautions from the FDA about fluoroquinolone side effects should be considered carefully. For simple, uncomplicated cystitis, norfloxacin is suggested. It is a quinolone specifically designed for lower urinary tract infections as it cannot be used for pyelonephritis.
• Pivmecillinam is not available in the US but is considered first-line therapy for uncomplicated UTIs elsewhere in the world. It is not recommended in pyelonephritis or suspected systemic infections due to inadequate tissue penetration. [49]

Even without treatment, UTIs will spontaneously resolve in about 20% of women, especially with increased hydration. The likelihood that a healthy nonpregnant female will develop acute pyelonephritis is very small.

Management of Recurrent UTIs

Managing recurrent UTIs typically involves optimizing personal hygiene, using vitamin C as a urinary acidifier, taking extra precautions after sexual contact, and using prophylactic antibiotics or antiseptics such as nitrofurantoin. [39]  (See the companion StatPearls reference article on "Recurrent Urinary Tract Infections.") [5]

• Nitrofurantoin low-dose long-term prophylaxis is the standard therapy for recurrent UTIs. The dosage is typically 50 mg QHS. It is well tolerated; treatment is limited to the urinary tract, which minimizes side effects, bacterial resistance is relatively low due to its multiple mechanisms of antibacterial activity, and allergies or intolerance is rare. [5]  Sulfamethoxazole/trimethoprim or trimethoprim alone are alternative agents. Norfloxacin and fosfomycin may also be used in selected cases.
• Methenamine is converted to formaldehyde in the bladder if the urinary pH is <5.5. Vitamin C is often used to help acidify the urine to achieve this pH level. Methenamine appears to be of some benefit in recurrent UTI prophylaxis, but some of the data is conflicting. [50] [51]  It may be useful as an alternative to antibiotics in selected patients. [52] [53]
• Cranberry  (juice, pills, extract) has also been suggested, and there is evidence of efficacy, although some of the data is contradictory. [51] [54] [55]  Some studies show a 30% to 40% reduction in UTIs, which is less effective than low-dose antibiotic therapy. [50] [54] [56]
• D-mannose has been used as a prophylactic agent, and there is evidence that it may provide some benefit. [57] [58] [59] [60] [61]  However, the available data is insufficient to formally recommend it. [5] [50] [51] [62] [63]
• Estrogen vaginal cream applied twice weekly can be helpful in postmenopausal women with atrophic vaginitis. [50] [64]
• Increased fluid intake is  helpful in women with low urinary volumes. [64] [65]

The duration of prophylactic treatment is generally 6 to 12 months. While this can be extended, limited data is available, and many patients must return to prophylactic treatment. [39] [66] [67]  Extending the prophylactic treatment period to 2 years has also been suggested. [68] [69]  

Diagnosis and management of recurrent UTIs are described in the American Urological Association Guidelines on Recurrent Urinary Tract Infections and in our companion StatPearls reference article on "Recurrent Urinary Tract Infections." [5] [39]

For relapsing infections (where the infecting organism is identical on all cultures), a careful examination should be done to look for a source, such as a poorly emptied diverticulum or an infected stone. [1]  See our companion StatPearls reference article on "Complicated Urinary Tract Infections." [1]

• Differential Diagnosis

The differential diagnosis of an uncomplicated UTI includes:

• Bladder stones
• Complicated UTI
• Food or dietary issues
• Herpes simplex
• Medication effects
• Overactive bladder
• Pelvic inflammatory disease
• Prostatitis
• Pyelonephritis
• Recurrent UTI
• Relapsing UTI
• Renal infarction
• Renal stones

The majority of women with a UTI have an excellent outcome. With antibiotic treatment, the duration of symptoms is typically 2 to 4 days. Nearly 30% of women will have a recurrence within 6 months. Morbidity is usually seen in older debilitated patients, patients with significant comorbidities, or those with renal calculi. Other factors linked to recurrence include diabetes, underlying malignancy, chemotherapy, and chronic Foley catheterization. The mortality after an uncomplicated UTI is close to zero. [65] [70]  

Factors predictive of a poor long-term outcome include:

• Advanced age
• Chemotherapy
• Chronic diarrhea
• Diabetes (particularly if poorly controlled)
• Incontinence
• Morbid obesity
• Nephrolithiasis
• Neuropathy or spinal cord injury
• Pelvic organ prolapse
• Poor overall health
• Previous overactive bladder
• Presence of malignancy
• Prior radiation therapy
• Sickle cell anemia
• Urethral catheterization

While mortality rates are low, the morbidity of UTIs is significant. Besides the distressing symptoms, the total cost of management is prohibitive. Missed work and school are common. In some cases, hospital admission is required due to the severity of the symptoms.

• Complications

Complications of UTIs include:

• Chronic prostatitis
• Emphysematous pyelonephritis and cystitis
• Focal renal nephronia
• Hypertension
• Persistent lower urinary tract symptoms
• Prostatic abscess
• Renal abscess
• Staghorn urinary calculi
• Deterrence and Patient Education

Once a UTI has been diagnosed, increased fluid intake should be encouraged. Patients should be informed of the importance of taking their medication as prescribed without stopping midway through the antibiotic course, even if they feel better. Patients should also be warned not to take prophylactic antibiotics unless prescribed, as future increased bacterial resistance may develop, making it more challenging to treat subsequent UTIs.

Preventative strategies to avoid UTIs are essential in reducing incidence and recurrence, especially in females. All women, particularly those at increased risk, should be educated regarding the following strategies:

• Women should urinate after sexual intercourse as bacteria in the bladder can increase tenfold after sexual activity.
• After urination, women should wipe from front to back, not from the anal area forward, which will contaminate the introitus and periurethral areas with pathogenic enteric organisms from the rectum.
• Vigorous, high-volume urine flow is helpful in prevention.
• Baths should be avoided in favor of showers.
• A gentle, liquid soap without fragrance, liquid baby soap, or baby shampoo should be used in bathing. Liquid soaps are cleaner than bar soap that can collect bacteria.
• When bathing, the soap should be applied using a freshly cleaned, soft cotton or microfiber washcloth.
• The vaginal area should be cleaned first to avoid unnecessary contamination of the periurethral area with bacteria on the washcloth if used elsewhere first.

Some women with recurrent UTIs may benefit from the prophylactic use of antibiotics. Several other nonmedical remedies may help women with UTIs. Anecdotal reports and some studies indicate that using cranberry juice, D-mannose, methenamine, and probiotics may help reduce the severity and frequency of UTIs in some women.

• Pearls and Other Issues
• Other than urinalysis and culture, no further evaluation is necessary for most women with an uncomplicated UTI.
• A urine culture from a patient with a successfully treated infection is more advantageous than a symptomatic patient after empiric therapy and no culture to guide treatment.
• Bacteriuria and pyuria without symptoms are not diagnostic for a UTI.
• Asymptomatic bacteriuria should generally not be treated except during pregnancy or an upcoming or recent invasive urologic procedure.
• Enhancing Healthcare Team Outcomes

UTIs are best managed in an interprofessional fashion. The key to preventing recurrences is patient education. Nurses can be particularly helpful with patient education. Primary clinicians should refer patients with relapsing or recurrent UTIs who fail prophylactic measures to urology.

Clinicians should work closely with a pharmacist and/or infectious disease professional to ensure the best antibiotic choices for treatment. Physicians should be familiar with bacterial resistance patterns in their communities. The pharmacist can verify the appropriate coverage, dosing, and duration. Patient and community safety benefits by ensuring optimal antibiotic selection, correct duration, and medication compliance. Nurses can chart progress, counsel the patient on compliance, answer patient questions, and report concerns or results to the clinical team.

All health care team members should follow the patient's progress. If they observe any issues, including therapeutic failure or adverse events from medication, they should communicate their findings and contact the appropriate team members for corrective actions. The earlier a UTI is managed, the better the prognosis. Optimal interprofessional team collaboration significantly enhances patient outcomes. [71] [72]  

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Disclosure: Michael Bono declares no relevant financial relationships with ineligible companies.

Disclosure: Stephen Leslie declares no relevant financial relationships with ineligible companies.

Disclosure: Wanda Reygaert declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Bono MJ, Leslie SW, Reygaert WC. Uncomplicated Urinary Tract Infections. [Updated 2023 Nov 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Optimising management of UTIs in primary care: a qualitative study of patient and GP perspectives to inform the development of an evidence-based, shared decision-making resource

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Background Urinary tract infections (UTIs) are one of the most common bacterial infections managed in general practice. Many women with symptoms of uncomplicated UTI may not benefit meaningfully from antibiotic treatment, but the evidence base is complex and there is no suitable shared decision-making resource to guide antibiotic treatment and symptomatic care for use in general practice consultations.

Aim To develop an evidence-based, shared decision-making intervention leaflet to optimise management of uncomplicated UTI for women aged <65 years in the primary care setting.

Design and setting Qualitative telephone interviews with GPs and patient focus group interviews.

Method In-depth interviews were conducted to explore how consultation discussions around diagnosis, antibiotic use, self-care, safety netting, and prevention of UTI could be improved. Interview schedules were based on the Theoretical Domains Framework.

Results Barriers to an effective joint consultation and appropriate prescribing included: lack of GP time, misunderstanding of depth of knowledge and miscommunication between the patient and the GP, nature of the consults (such as telephone consultations), and a history of previous antibiotic therapy.

Conclusion Consultation time pressures combined with late symptom presentation are a challenge for even the most experienced of GPs: however, it is clear that enhanced patient–clinician shared decision making is urgently required when it comes to UTIs. This communication should incorporate the provision of self-care, safety netting, and preventive advice to help guide patients when to consult. A shared decision-making information leaflet was iteratively co-produced with patients, clinicians, and researchers at Public Health England using study data.

• drug resistance, microbial
• qualitative research
• urinary tract infections
• INTRODUCTION

There are few public health issues of greater importance than antimicrobial resistance (AMR). 1 In response to the O’Neill Review, 2 the UK Secretary of State for Health stated an important ambition: to reduce inappropriate antimicrobial prescribing by 50% by 2021.

Urinary tract infections (UTIs) are the most commonly seen bacterial infection in general practice. 3 Three-quarters of women will have a UTI in their lifetime, with Escherichia coli ( E. coli ) being the causative pathogen in 70–95% of cases. 4 In a recent study, 95% of women consulted a health professional for their most recent UTI; 74% reported being prescribed an antibiotic. 5 Another study 6 found that only 35.8% of urine samples cultured for suspected UTIs met laboratory threshold for UTI, suggesting that some symptomatic episodes may not be caused by bacterial infection in the urine.

Suboptimal diagnosis and management may contribute to treatment failure that may lead to upper UTI and in some cases a blood stream infection. Women that have taken antibiotics recently and those who experience recurrent episodes (three in the past 12 months) are more likely to present with an antibiotic-resistant infection. 7 Antibiotic-resistant urine infections in primary care are symptomatic for longer and are more expensive to treat. 8 , 9 By improving shared decision making, 10 self- care, and prevention this could reduce recurrent infections and improve women’s health and wellbeing. Stewardship programmes and educational initiatives in the primary and secondary care settings are being increasingly implemented to improve the quality of appropriate prescribing. A recent respiratory tract infection patient-facing information leaflet has been welcome. 11 The authors were unable to identify any up-to-date, evidence-based, shared decision-making resource for use with patients consulting with symptoms of uncomplicated UTI. 12

An understanding of the patient and GP behaviour during the consultation process, underpinned by behavioural theory, should help increase the likelihood of success of any intervention developed using the data to optimise the management of UTIs. There are many theories of behavioural change; however, the Theoretical Domains Framework (TDF) combines constructs from multiple theories into a single framework, which can be used to assess implementation and other behavioural problems, and inform intervention design. 13

This study aimed to utilise the TDF to explore barriers to effective communication and prescribing, and develop a patient-facing UTI leaflet for women aged <65 years to help optimise the management of UTIs in the primary care setting.

Participant selection and recruitment

Patient recruitment.

Women who were aged ≥16 years, who had experienced a UTI in <12 months, and previously consulted a GP regarding their symptoms, were invited via the Public Health England (PHE) People’s Panel (comprises 1600 members of the public who were recruited through a national random sample survey) to take part in a focus group to discuss their previous experience of a UTI and GP consultation. All responders fitting the aforementioned criteria were invited to take part in a focus group. Panel members were sent a letter of invitation with a study information leaflet, and were given 95 GBP towards their travel and costs for the day.

How this fits in

GP recruitment

A study recruitment item was issued in the Royal College of General Practitioners (RCGP) clinical news newsletter, seeking GPs with previous experience of consultations with women who had a UTI to take part in a 30-minute telephone interview to discuss their views of UTIs and their experience of UTI consultations. The newsletter went out to all RCGP members. GPs were offered a 20 GBP high-street voucher in acknowledgement of their contribution to the study.

Interview schedule

Facilitators used a flexible interview schedule exploring all aspects of the management of UTI based on the TDF 13 and included both closed and open-ended questions (Supplementary Table S1).

The focus group schedule aimed to evaluate women’s experiences of UTI; any associated GP consultation; their attitudes towards self-caring for their urinary symptoms; their attitudes towards preventive measures; and their needs and expectations from a GP consultation.

The GP interview schedule aimed to evaluate the GP decision-making process; their views on patient expectations; their interaction with the patient during the consultation; and their provision of self-care and preventive measures information. To help identify and eliminate bias, GPs were also asked whether they had a specific interest in UTI research.

Interviews were carried out by trained researchers with no clinical knowledge of, or personal experience of, UTIs. Following the interview, participants were asked to comment on a draft version of a UTI information leaflet.

Each GP telephone interview lasted approximately 30 minutes; focus groups lasted approximately 2 hours.

All participants gave informed consent prior to interview.

Intervention development

Leaflet development was an iterative process based on findings from both the patient and GP interviews. An initial draft leaflet was developed based on research expertise in the area of UTI and leaflet development. 14 This draft was shown to participants at the first focus group and the first five GPs who were interviewed. Based on comments received from experts in the field and interview findings, the leaflet was then modified and version 2 was shown to the next focus group and the next five GPs. The process continued, version 3 to version 4, and so on, until data saturation was achieved and all interviews were complete.

Data analysis

All interviews were recorded, with permission, and transcribed verbatim by a professional company. A researcher reviewed them for accuracy. Two researchers independently read transcripts multiple times, coded the transcripts based on the TDF domains, and performed thematic analysis. To assess researcher consensus, all extracted themes and subthemes were reviewed in a meeting. Disagreements were discussed and a final theme or subtheme was chosen. The use of NVivo software (version 10) facilitated the organisation of the data. The one sheet of paper (OSOP) method was used to clarify findings within, and between, themes. 15

Between June and October 2016, 29 women were interviewed across four focus groups in three areas of England: London ( n = 14), Birmingham ( n = 8), and Leeds ( n = 7). Women varied in age, ethnicity, and the number of UTIs they experienced in the past year ( Table 1 ). Twenty individual GP interviews took place over the phone. Over half of GPs were salaried GPs ( n = 12) with no specific interest in research. Further GP demographics can also be seen in Table 1 .

• View inline

GP and patient demographics

Meta-themes

Data analysis identified key domains from the TDF that influenced GP and patient behaviour associated with the management of urinary symptoms (Supplementary Table S1). In comparing the patient and GP responses based on the TDF, five meta-themes were identified ( Table 2 ) that highlight differing views between the GP and patient regarding the consultation process and treatment of UTIs.

Overarching meta-themes identified from GP and patient interviews

Patient knowledge of UTIs

GPs reported that they believed women were quite knowledgeable about UTIs, either because women talk to each other about their UTI or because they have had previous personal experience of a UTI: ‘UTIs are very, generally a very quick consultation, women seem to know a lot about them.’ (GP2)

This study found a large variation in patient knowledge around UTIs. Many women felt that a UTI was something that happened to them that they could not control. Many felt it to be a private matter and some expressed that this [the focus group] was the first time they had spoken openly about their UTI to other women. Interviews highlighted a lack of knowledge in the following areas.

First, UTI experience: many women discussed not knowing what was happening to them when they had their first UTI and what to do about it. They described not going to see their GP until either the pain got ‘too bad’ or until their second episode: ‘My first time I were diagnosing myself, like, oh, it’s kidney stones or it’s this or my gall, it, I was blowing it out of proportion kind of thing …’ (FG [focus group] 4)

Second, prevalence: some women expressed shock at learning how prevalent UTIs were. Older women wrongly assumed that it was age related, expressing surprise at seeing younger women in attendance: ‘It’s obviously far, far, far more prevalent than I realised. I thought for example it was older … I thought I was just very young to be getting these things.’ (FG1)

Third, types of UTI and causes of urinary symptoms: there was a lack of knowledge about the causes of urinary symptoms and the different types of UTI, particularly the difference between cystitis (bladder infection) and other UTIs (for example, kidney infection). The women appeared to associate a UTI with intense pain and did not view cystitis as a painful enough illness to call it a UTI: ‘I’ve had cystitis maybe twice, and that’s a different, but the one I had with the UTI was a completely different situation.’ (FG2)

None of the women appeared to know that urinary symptoms can be caused by inflammation or infection of the urethra post-sexual intercourse, although many associated sexual intercourse with the development of a UTI.

View of the consultation

Although many GP participants reported managing the condition by telephone, they said that they carried out a similar routine when consulting face-to-face. They report being skilled at liaising with the patient and listening to their symptoms, diagnosing a UTI and providing the appropriate treatment: ‘… you just let the patient talk for a minute and see what they say … you might not need to ask them any of the extra questions, to be honest.’ (GP1)

As many of the GPs reported that they considered women were already quite knowledgeable, they saw the UTI consultation as quite a straightforward process. In contrast, women felt that they were not being heard, possibly because they were not asked many questions. Many felt that GPs viewed the consultation as routine, showing lack of empathy or understanding of the patient’s needs, and hurried the consultation to catch up on time: ‘If you have a doctor who is willing to forget about the time he’s got for each patient and sit down and listen to you and let you explain … But when they have this time limit, 10 minutes, they shoo you away.’ (FG2)

Treatment expectations

Most GPs reported that women expected antibiotic therapy for their UTI: ‘People expect antibiotics usually.’ (GP18)

Some stated that their prescribing behaviour is influenced by the patient: ‘Oh I think they always influence what we do … I think it’s unlikely that a GP can say they’ve never been influenced by a patient to prescribe antibiotics because, at the end of the day, there are certain demands on our time and that does happen, and that sometimes may be for lack of back-up, lack of resources.’ (GP10)

Some also expressed concern about how late women present with a UTI and the fear of upper tract infections; as such, GPs reported a low antibiotic prescribing threshold: ‘I think certainly any systemic upset, have a low threshold for obviously treating that because you’re worrying about your upper tract infections and I’m sure most people would say the same.’ (GP20)

Patient’s antibiotic prescribing expectations varied; while women wanted treatment for the pain, they did not necessarily want a quick fix that might not be best for them: ‘… as in here’s a cure, off you go. Maybe how did you get it, why you’ve got it, what you can do to prevent it again.‘ (FG2)

Their needs centred on advice on symptom duration, and pain and discomfort management: ‘There must be something you can put like a cream that’ll make it go cold.’ (FG1)

They wanted validation of their illness; and reassurance that the infection will not ‘move to the kidneys’: ‘ You don’t need a prescription all the time … You just maybe need a bit of reassurance.’ (FG2)

However, those who were prescribed antibiotics said that they would take them out of fear: ‘… getting the antibiotics and taking them might be better than not taking them at all because you don’t know what could develop within that 48 hours.’ (FG1)

There were a few women who expressed a preference for immediate antibiotic therapy. This preference was usually based on their experience of successful past treatment with antibiotics: ‘When I have the antibiotics it gets rid of it.’ (FG4) ‘… was spiking a very high temperature and feeling like I had the flu, I would go to the GP and I would want antibiotics, to be honest with you, because if it gets to that stage it can go to your kidneys, and that’s dangerous.’ (FG1)

Self-care, safety netting, and prevention

GPs stated that they tailored advice to the individual patient; usually gave self-care advice to patients presenting with UTI symptoms for the first time; and provided more detailed information to those with recurring episodes: ‘If she’s only had one or two [episodes] or something like that … I usually say drink lots of fluids. If it’s someone who’s had like more long-term ones, you might talk more about things like: is there an aching after sex or things like that … But it depends often in the individual cases … ’ (GP3)

The majority of GPs stated that they always provided safety-netting advice, mainly because of concern about the infection deteriorating. Few GPs provided self-care or prevention advice citing a lack of supporting evidence: ‘How to help prevent, I probably don’t particularly mention those, because again that’s because there’s not the evidence there, so I don’t bother to go into it.’ (GP5)

In contrast to GP reasoning, it was the women who had less experience of a UTI who were keen to receive self-care and prevention advice: ‘I found that when I went to the doctor’s for the advice … you weren’t getting much information.’ (FG3)

Women who had recurrent UTI had developed their own self-care routine.

Women with only one or two episodes of UTIs were unaware of any preventive measures they could take; however, they were eager to receive such information and were prepared to make behavioural changes as a result: ‘I would like more information about what we can do for ourselves.’ (FG3)

Awareness of AMR

All GPs were very aware that AMR is a huge problem: ‘It’s a really big problem. It’s a problem across the whole board.’ (GP14)

Interviewer: ‘Have you ever encountered treatment failure because of resistance?

GP13: Oh yeah, definitely, yeah. Have I ever seen treatment failure because of resistance? Oh yes of course …’

Patients also reported being aware of AMR, although some women thought that it was the individual who became resistant to the antibiotics rather than the infecting organism: ‘I’m aware that there’s going to come a time when my body’s going to reject them [the antibiotic] .’ (FG4)

Patients were concerned by information provided by the facilitators that effective antibiotics may not be available in the future, and for many this guided their opinions as to whether or not they needed and/or wanted antibiotics for their UTI: ‘… I’ve got a feeling they’re going to stop giving antibiotics.’ (FG3)

Despite being aware of AMR, participants who were previously prescribed antibiotics for their urinary symptoms expressed strong views on the need for antibiotics in every case to treat their UTI: ‘… now I know the first signs and I just know that I need those antibiotics … I just need a dose of antibiotics and then it’s gone.’ (FG1)

One woman stated that the information that antibiotic use increases the risk of resistance may be of benefit to someone who is ‘new to UTIs’: ‘If I was shown this and I read this stuff about antibiotics … maybe I can live with my symptoms for another 24 hours if I have rushed off to the doctor at the first little twinge. Not necessarily in my position but somebody who was new to UTIs.’ (FG1)

Barriers to an effective joint consultation and appropriate prescribing that emerged from the analysis included: lack of GP time; misunderstanding of depth of knowledge between GP and patient; miscommunication between the patient and the GP; nature of the consults (for example, telephone consultations); a history of previous antibiotic therapy; and the lack of a succinct, up-to-date summary of the evidence base with implications for management ( Figure 1 ).

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Barriers to effective communication of the UTI consultation and optimal prescribing.

UTI = urinary tract infection.

The UTI leaflet

The authors used interviewee suggestions, and the barriers identified from the data analysis, to co-develop a patient-facing leaflet to be used during consultations with females presenting with a suspected non-complicated UTI. The TARGET Your Infection — Urinary Tract Infection (TYI—UTI) information leaflet for uncomplicated UTIs was designed to be shared during the consultation and taken home by the patient for future reference (Supplementary Figure S1). 16 When used in this way the leaflet aims to facilitate dialogue between the GP and patient, covering the areas of misunderstanding found in this study, including the management decisions, safety-netting advice, antibiotic resistance, prevention of a UTI, and shared decisions about management. Six main evidence-based sections each address ≥1 of the aforementioned barriers to effective consultation. All six main evidence-based sections combined provide a succinct, up-to-date summary of the evidence base with implications for management:

Possible urinary symptoms: addresses the knowledge, misunderstanding, and lack of skills barriers. It acts as a checklist for GPs and shows the patient that the GP is considering their symptoms.

Outcomes and recommended care, developed in line with national UTI prescribing guidance: addresses the misunderstanding, lack of skills, and history of prescribing barriers. It outlines the patient care plan options while providing the GP with evidence as to why they do not always need to prescribe antibiotics.

Types of urinary infections using a pictorial guide: addresses the knowledge barrier. Women felt that being able to visualise where and what their UTI was gave them a better understanding of their condition.

Self-care and safety-netting advice: addresses the misunderstanding and lack of skills and time barriers. This facilitates information sharing without using the consultation time.

Preventive advice: addresses the misunderstanding and lack of skills and time barriers. Women felt this information was invaluable for their future health.

Antibiotic resistance: addresses the misunderstanding, lack of skills and time, and history of prescribing barriers. GPs are provided with a reference as to why antibiotics are not always the best treatment option while educating the patient on the dangers of unnecessary antibiotic use.

The fully referenced leaflet provides the GP with the evidence base they felt was previously lacking (Supplementary Figure S1). 16

This study used the TDF to develop an interview schedule to help identify patient and GP attitudes towards UTIs and the consultation process. The meta-themes highlight a difference of opinion, or misunderstandings, between the GP and the patient. Examination of the data using the TDF suggests that these misunderstandings can be explained by lack of effective communication between the patient and the GP. A draft evidence-based leaflet to enhance shared decision making in the consultation was co-developed with patients, clinicians, and researchers at PHE that aims to address identified barriers to effective communication about symptoms of uncomplicated UTI.

Strengths and limitations

A strength of this study lies in capturing the views of women who all, apart from one, had experienced a UTI and a GP consultation for a UTI in <5 years; were from a diverse age range; and varied in their frequency of UTI occurrence. These findings are particularly important because they reflect current issues experienced by women.

A further strength is that neither of the interviewers had clinical knowledge of, or personal experience of, UTIs; therefore, they could not bring unconscious bias to either the interviews or data analysis.

Although there were almost twice as many female to male GPs interviewed, all GPs had previously diagnosed a UTI; were widespread across England; varied in the number of years in practice and practice size; and were from across a range of urban and suburban practices.

Gaining insight from both the patient and GP perspective allowed comparison of participants’ perceptions and identified differences between the groups.

A study limitation is that there were no interviews conducted with prescribing nurses who often consult for patients who have a suspected UTI; they may have had different opinions from the GPs.

The authors deliberately chose not to ask women about consultations with urgent care and walk-in centre clinicians, which may be viewed as a study limitation; however, this is a very different clinical setting and would require the attention of a separate study.

Although the interviews were carried out across England, no participant addresses or information were collected on where they may have lived when they had previous UTIs. As such, it is unknown if the GP consultation being discussed happened in a rural or urban practice, which may influence the findings.

Comparison with existing literature

Effective doctor–patient communication is an integral part of the consultation process that achieves an evidence-based prescribing decision while maximising patient empowerment and satisfaction with care. 10 , 17 – 20 Effective collaborative communication can have beneficial effects for both the patient and the doctor, allowing for a satisfactory and informative consultation while fostering a meaningful and trustworthy relationship. 21 – 23 On the other hand, lack of effective communication can leave patients feeling disempowered, frustrated with their care, and less likely to adhere to their treatment regimen. 21

Worryingly, the study findings around the lack of symptom information shared between the doctor and patient mirrored that of research around UTI published in 1998, 24 suggesting that little has changed in the past 20 years. GPs participating in the present study reported that they often did not feel the need to further question the patient after giving them the ‘golden minute’ to explain their symptoms. Rink 24 also found that GPs varied in how they questioned patients about their symptoms. This current study also identified patient frustration resulting from the lack of exploration by the GP about their condition, or the internalisation of the GP thought process, resulting in the patient feeling either reluctant to question the GP’s decision or discuss their concerns on a subject that some feel embarrassed about. Research in 2010 highlighted that women can struggle to discuss the symptoms of UTIs. 25 This suboptimal communication may lead to a misdiagnosis, inappropriate prescribing of antibiotics, and lack of patient education, which in turn may result in increased patient expectation for antibiotic therapy.

GPs from the present study stated that many women do not seek medical intervention until quite late, which correlates with findings from other studies focusing on patients’ views. These studies highlight that women only consult when the severity of symptoms, the duration of illness, or failed self-care are sufficiently severe to prompt a visit. 25 , 26 GPs suggest that this lack of early consultation can result in them having a low prescribing threshold because of fear of complications.

Although GPs in the present study reported that women almost always expected antibiotic treatment, the authors, and other researchers, 25 , 27 found that many women interviewed were open to, and some even preferred, an alternative to antibiotic therapy. Those who had a preference for, or expectation of, antibiotic therapy usually had experienced successful antibiotic treatment. 25 Although antibiotic therapy for UTIs may be seen by many GPs as the most effective treatment, as few as 25% of women with urinary symptoms may have a UTI proven on culture, and many with symptoms of uncomplicated UTI recover without antibiotic treatment. 6 , 28 Antibiotic resistance is increasing; therefore, a reduction in antibiotic use is needed. Studies have found that women with UTI symptoms are willing to delay antibiotic treatment when asked by their GP. 25 , 29 The 2018 National Institute for Health and Care Excellence (NICE) antimicrobial prescribing guidance for UTIs (lower) suggests offering a delayed or back-up antibiotic prescription 30 for those not requiring immediate treatment. However, if women are asked to delay taking an antibiotic, the rationale behind the decision must be clearly explained and the patient’s worries addressed. 25

Implications for practice

Consultation time pressures, combined with late symptom presentation, are a challenge for even the most experienced of GPs; however, it is clear that enhanced patient–clinician shared decision making is urgently required when it comes to UTIs. Using the developed UTI patient information leaflet as an educational and reference tool, and personalising it in consultations, might enhance patient empowerment by either considering and building in preventive measures to their daily lives; better self-care when urinary symptoms present; or recognising when to visit their GP following the identification of urinary symptoms; all of which may reduce the need for unnecessary antibiotic therapy and prevent E. coli bacteraemia, reconsultations, or hospitalisations. Further research should involve evaluation of the leaflet 16 in the primary care setting to assess its effectiveness in improving the management of women aged <65 years presenting to a GP with urinary symptoms.

The TARGET Your Infection UTI information leaflet has been endorsed by NICE 31 and is freely available via the TARGET antibiotics website ( http://www.rcgp.org.uk/TARGETantibiotics ), or via supplementary data available at the present article’s location on the BJGP website. To maximise use the leaflet should be promoted via GP computer systems, NHS information sources, and through other professional bodies.

• Acknowledgments

A warm thank you to all participants who gave up their time to be interviewed, and to the expert advisers who reviewed and provided comments on numerous iterations of the draft leaflet.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical approval

This study fell into the category of service evaluation, therefore NHS ethical approval was not required, in accordance with the National Research Ethics Service research guidelines. As such, a waiver of approval was not required or sought from the South West Multicentre Research Ethics Committee [MREC]. A letter of exemption for the study from the Public Health England research and governance office was received.

Freely submitted; externally peer reviewed.

Competing interests

Donna M Lecky manages the TARGET antibiotic toolkit for Public Health England. Cliodna AM McNulty leads the development and writes evidence-based antibiotic and diagnostic guidance for primary care, including UTI guidance. Any payment for speaking at a conference goes to a research trust fund. Chris C Butler holds publicly funded grants to research aspects of UTI in primary care and has received a fee for lecturing on UTI.

Discuss this article

Contribute and read comments about this article: bjgp.org/letters

• Received May 21, 2019.
• Revision requested July 23, 2019.
• Accepted August 22, 2019.
• ©The Authors

This article is Open Access: CC BY-NC 4.0 licence (http://creativecommons.org/licences/by-nc/4.0/).

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Case Study Of A Complicated UTI

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• Published: 24 November 2023

7295 elderly hospitalized patients with catheter-associated urinary tract infection: a case-control study

• Li Shen 1 , 6 ,
• Ting Fu 2 ,
• Luguang Huang 3 ,
• Huiying Sun 1 ,
• Yu Wang 4 ,
• Lili Sun 5 ,
• Xiaoyun Lu 1 ,
• Jing Zhang 1 ,
• Zhaoxu Yang 1 &
• Chunping Ni 6  

BMC Infectious Diseases volume  23 , Article number:  825 ( 2023 ) Cite this article

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Catheter-associated urinary tract infection (CAUTI) ranks second among nosocomial infections in elderly patients after lung infections. Improper treatment can lead to death. This study analysed the risk factors, pathogen distribution, clinical characteristics and outcomes of CAUTI in elderly inpatients with a large sample size to provide evidence for clinical prevention and control.

Based on the HIS and LIS, a case‒control study was conducted on all hospitalized patients with indwelling urinary catheters ≥ 60 years old from January 1, 2019, to December 31, 2022, and the patients were divided into the CAUTI group and the non-CAUTI group.

CAUTI occurred in 182 of 7295 patients, and the infection rate was 3.4/per 1000 catheter days. Urine pH ≥ 6.5, moderate dependence or severe dependence in the classification of self-care ability, age ≥ 74 years, male sex, hospitalization ≥ 14 days, indwelling urinary catheter ≥ 10 days, diabetes and malnutrition were independent risk factors for CAUTI ( P  < 0.05). A total of 276 strains of pathogenic bacteria were detected in urine samples of 182 CAUTI patients at different times during hospitalization. The main pathogens were gram-negative bacteria (n = 132, 47.83%), followed by gram-positive bacteria (n = 91, 32.97%) and fungi (n = 53, 19.20%). Fever, abnormal procalcitonin, positive urinary nitrite and abnormal urination function were the clinical characteristics of elderly CAUTI patients ( P  < 0.001). Once CAUTI occurred in elderly patients, the hospitalization days were increased by 18 days, the total hospitalization cost increased by ¥18,000, and discharge all-cause mortality increased by 2.314 times ( P <0.001).

The situation of CAUTI in the elderly is not optimistic, it is easy to have a one-person multi-pathogen infection, and the proportion of fungi infection is not low. Urine pH ≥ 6.5, moderate or severe dependence on others and malnutrition were rare risk factors for elderly CAUTI in previous studies. Our study analysed the clinical characteristics of CAUTI in the elderly through a large sample size, which provided a reliable basis for its diagnosis and identified the adverse outcome of CAUTI.

Peer Review reports

Urinary catheterization assisted by an indwelling urinary catheter is essential in treating most diseases. It not only brings clinical convenience but also becomes a significant risk factor for urinary tract infection (UTI). The aging of the global population is developing rapidly [ 1 ]. The problem of nosocomial infection in elderly patients has received increasing attention. Several studies have shown that advanced age is a significant risk factor for catheter-associated urinary tract infection (CAUTI) [ 2 , 3 , 4 ].Improper treatment can lead to death, and the case fatality rate is approximately 6.2% [ 5 ].

Approximately 20% of patients need indwelling urinary catheters during hospitalization, especially elderly patients [ 6 ]. In the UK, there are approximately 90,000 long-term catheter users [ 7 ]. Surveys from 11 European countries show that 5.4% of people over 65 need long-term indwelling urinary catheters [ 8 ]. However, the immunity of elderly patients decreases with age, and coupled with the gradual decline in organ function, the risk of related infection will increase. In fact, most elderly and stroke patients have a long-term bedridden status, further decline in immunity and so on. In this case, UTIs occur easily.

Although the incidence of CAUTI is high, accounting for approximately 40% [ 9 ] of nosocomial infections, 65-70% of CAUTIs are preventable [ 10 ]. The existing prevention and control measures are still based on early extubation and reduction of unnecessary indwelling catheters [ 11 ]. Nevertheless, it is not necessarily applicable based on the disease characteristics of elderly patients. The most critical risk factors for CAUTI in elderly patients are a long indwelling urinary catheter and a long hospitalization time. This is usually because the condition is severe and takes a long time to recover. Therefore, we urgently need to carry out a large sample of high-quality clinical research for elderly patients to seek effective prevention and control measures for elderly patients who need an indwelling urinary catheter.

Study design and participants

All patients were ≥ 60 years old with indwelling urinary catheters during hospitalization from January 1, 2019, to December 31, 2022. Inclusion criteria: ① Patients ≥ 60 years old; ② Patients with indwelling urinary catheter>2 days (calendar days). Exclusion criteria: ① Confirmed UTI or indwelling urinary catheter before admission; ② No routine urine test was performed before indwelling urinary catheter was placed in this hospital. ③ This hospitalization was related to urinary system diseases; ④ Research variables and indicator-related information were incomplete; ⑤ Patients with acidosis, alkalosis and hyperuricemia were diagnosed before or during hospitalization; ⑥ Military retirees or patients with continuous hospitalization for more than one year due to medical disputes. This study was approved by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University (XJLL-KY-20,232,139).

Obtainment of informed consent from each participant was waived by the Ethics Committee of the First Affiliated Hospital of Air Force Medical University due to the nature of the study. All methods were performed following the Ethical Review of Biomedical Research Involving Human Beings issued by the National Health and Family Planning Commission of China.

Diagnostic criteria

The diagnosis of CAUTI was carried out according to the American CDC/NHSN [ 12 ]: 1.The patient had an indwelling urinary catheter that had been in place for > 2 days on the date of the event (day of device placement = Day 1) and was either still present on the date of the event or removed the day before the date of the event. 2. The patient had at least one of the following signs or symptoms: (1) fever (> 38.0 °C).(2) suprapubic tenderness. (3)costovertebral angle pain or tenderness. 3.The patient had a urine culture with no more than two species of organisms,at least one of which was a bacteria of ≥ 10 5 CFU/ml. If more than two types of microorganisms were isolated, the sample was considered to be contaminated.

The CAUTI rate per 1000 urinary catheter days was calculated by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000.

Etiological examination

The quality control strains Staphylococcus aureus ( S.aureus ) (ATCC29213), Escherichia coli ( E.coli )(ATCC25922), Klebsiella pneumoniae ( K.pneumoniae ) (ATCC700603), and Pseudomonas aeruginosa ( P.aeruginosa ) (ATCC27853) were all purchased from the Clinical Laboratory Center of the National Health Commission. Urine samples were collected from suspected CAUTI patients and sent to the clinical laboratory within 2 h. After that, the specimens were inoculated into the corresponding media(sheep blood agar medium was used for bacteria, and Sabourand agar medium was used for fungi) and identified using a VITEKMS microbial mass spectrometer (BioMérieux, France) according to the fourth edition of the National Clinical Laboratory Procedures.

The same pathogen detected in the urine samples of the same patient at different times was counted as only one strain.

Statistical analysis

SPSS 26.0 was used for statistical analysis. Counting data are expressed in frequency and percentage terms, and measurement data are described by the mean ± standard deviation or median (interquartile distance) according to whether the data conformed to a normal distribution. The critical value of clinical significance was determined by the ROC curve Youden index according to the target status value (CAUTI or not) of age, days of hospitalization, days of indwelling urinary catheter and urine pH value, which were divided into two subgroups. An independent sample t test was used to compare the means of normally distributed variables, and the Wilcoxon rank sum test was used to compare the means of nonnormally distributed variables. The rate was compared by the chi-square test. Univariable and multivariable logistic regression models were used to analyse the associations between risk factors and CAUTI. Odds ratios (OR) with 95% confidence intervals (CI) were estimated. P  < 0.05 was considered to be statistically significant.

Risk factors for patients with CAUTI

A total of 7295 patients with indwelling urinary catheters were included in our study. The catheter was used for 53,523 days. There were 3926 males and 3369 females, aged 60–102 years, with a median age of 68 (64,75) years. Among the 7295 subjects, there were 7113 cases in the non-CAUTI group and 182 cases in the CAUTI group, and the infection rate was 3.4/1000 catheter days.

In addition, we further analysed the risk factors for CAUTI. Univariate logistic regression analysis showed that all variables except for sex ( p =  0.994) had statistical significance ( p  < 0.001) (Table  1 ). Moreover, after all variables were analysed by regression model, the results showed that urine pH ≥ 6.5 ( OR  = 24.292, 95% CI 15.736~37.499), moderate dependence( OR  = 6.198, 95% CI 2.681~14.328) or severe dependence( OR  = 5.985, 95% CI 2.848~12.579) in the classification of self-care ability, age ≥ 74 years old OR  = 1.514, 95% CI 1.036~2.212, male OR  = 1.483, 95% CI 1.031~2.135, hospitalization ≥ 14 days OR  = 7.500, 95% CI 4.408~12.762, indwelling urinary catheter ≥ 10 days( OR  = 6.352, 95% CI 3.941~10.236), diabetes OR  = 2.602, 95% CI 1.748~3.871, malnutrition OR  = 2.718, 95% CI 1.829~4.040were independent risk factors for CAUTI ( p <0.05)(Table  2 ).

Distribution of opportunistic pathogens detected in urine samples of patients with CAUTI

A total of 276 strains of pathogens were detected in urine samples of 182 CAUTI patients at different times during hospitalization, mainly gram-negative bacteria (n = 132, 47.83%), followed by gram-positive bacteria (n = 91, 32.97%) and fungi (n = 53, 19.20%). The most common pathogens included Enterococcus faecium ( E.faecium ) (n = 73, 26.45%), E.coli (n = 44, 15.94%), K. pneumoniae (n = 40, 14.49%) and Candida albicans ( C.albicans ) (n = 28, 10.14%) .More than one pathogen was detected in 70 patients. (Table  3 ).

History of pre-infection antimicrobial therapy in patients with E.coli and E.faecium

The average number of days that patients with E.coli received antimicrobial therapy prior to infection diagnosis was 0 (0, 8) days, 11.5 (7.5, 23) days for E.faecium patients, and 18 (9,26) days for patients infected with both pathogens. There were 31 patients with E.coli infection, of whom 16 (51.64%) had not received antimicrobial therapy before infection, 60 patients with E.faecium infection, of whom 57 (95.00%) had received antimicrobial therapy before infection, and 13 patients with both pathogens had received antimicrobial therapy before infection( p <0.001)(Table  4 ).We also found that the antimicrobial exposure history of patients infected with E.faecium in this group was mainly the third-generation cephalosporins and carbapenems(Table  5 ).

Analysis of clinical characteristics of patients with CAUTI

The subjects were divided into two groups according to CAUTI and non-CAUTI status. The results showed that the proportions of patients with fever, abnormal procalcitonin, positive urinary nitrite and abnormal urination function were higher than those in the non-CAUTI group ( p  < 0.001) (Table  6 ).

Outcomes of patients with CAUTI

Finally, we analysed the factors affecting the prognosis of patients with CAUTI. Compared with the non-CAUTI group, the hospitalization days of the CAUTI group increased by 18 days (10 vs. 28 days), the total hospitalization cost increased by ¥18,000 (89,000 vs. 107,000 yuan), and discharge all-cause mortality increased by 2.314 times ( OR = 3.314, 95% CI 2.002~5.488) ( p <0.001) (Table  7 ).

Our study divided the urine pH value into two subgroups based on the critical value judged by the ROC curve Youden index. The results showed that a urine pH value ≥ 6.5 was an independent risk factor for CAUTI. The median urine pH value in the CAUTI group was 7 (6.5, 7.5) and that in the non-CAUTI group was 6 (5.5, 6.5). This is rare in previous studies. We chose the timing of the urine pH study at the initial admission stage and before the indwelling catheter. The main reason is to reduce the research bias of urine results caused by disease treatment and invasive operation. It is well known that an acidic environment is not conducive to bacterial growth [ 13 ], and acidic urine also has a certain protective effect on CAUTI, as confirmed in our study. In clinical practice, we can use this conclusion as a guide through high-safety intervention methods to maintain the urinary environment of patients with catheterization in the normal range and pH < 6.5, which is conducive to the prevention of CAUTI.

We found that moderate dependence or severe dependence in the classification of self-care ability was an independent risk factor for CAUTI. The self-care ability grade in this study is that patients are graded by nurses in charge of the Barthel index rating scale at admission, which can truly reflect the patients’ self-care ability. The self-care ability score scale mainly measures the patients’ ability to eat independently, take a bath, go to the toilet, walk and so on. Many previous studies have shown that cerebrovascular disease, paraplegia or dyskinesia are risk factors for CAUTI [ 4 , 14 , 15 ]. This kind of patient has an increased incidence of CAUTI due to the limitation of activity caused by disease, which is consistent with the conclusion of this study.

In addition, our study shows that males are more prone to CAUTI than females, which is different from previous studies [ 15 ]. Advanced age, long hospital stay, long indwelling urinary catheter and diabetes have been unanimously recognized as risk factors for CAUTI in many previous studies [ 16 , 17 , 18 ], which is no exception in our study.However, our research has clarified the time characteristics of CAUTI in elderly individuals.

Malnutrition in the elderly has been shown to be associated with an increased risk of hospitalization and death [ 19 ]. In our study, it was shown that it is an independent risk factor for CAUTI, suggesting that nutritional status assessment is a very important issue in the process of diagnosis and treatment. Improving the nutritional status of elderly individuals is one of the strategies to prevent and control infection, and early intervention should be carried out.

In our study, 276 strains of opportunistic pathogens were detected in 182 cases of CAUTI. The distribution of pathogens was mainly gram-negative bacteria, followed by gram-positive bacteria and fungi. The primary pathogen causing CAUTI is E.faecium , followed by E.coli, K.pneumoniae and C.albicans , which differs from some studies [ 20 , 21 , 22 ]. This is mainly because E.faecium and E.coli are usually parasitic in the human intestinal flora and elderly individuals due to physical function decline, low immunity, many primary diseases and other reasons. This provides an opportunity for bacterial invasion. It is inferred that the occurrence of CAUTI in elderly individuals is closely related to endogenous infection. At the same time, E.faecium was the most common pathogen in this study, which was different from previous reports. We reviewed the history of antimicrobial exposure during hospitalization in this patient population from the first day of admission until the first diagnosis of CAUTI caused by E. coli or E. faecium .We found that patients infected only with E.faecium and with both pathogens had a high probability of receiving antimicrobial therapy, and the time was longer than that of patients infected only with E.coli. There were 31 patients infected only with E.coli , 16 of whom had not received antimicrobial therapy before infection, and 60 patients infected only with E.faecium , 57 of whom had received antimicrobial therapy before infection.The high incidence of E.faecium is related to the history of antimicrobial exposure.We also found that the antimicrobial exposure history of patients infected with E.faecium in this group was mainly third-generation cephalosporins and carbapenems,while Enterococcus was naturally resistant to cephalosporins.When E.coli and E. faecium are both opportunistic intestinal parasitic pathogens, the tendency of clinicians in this hospital to use drugs leads to E.faecium becoming the dominant pathogen, with a higher incidence than E.coli. In addition, the incidence of C.albicans infection is not low, accounting for 10.14%, which is different from the distribution of UTI pathogens in nonelderly patients [ 23 ]. It is considered that it is mainly related to many kinds of pathogens in the elderly and the extensive use of broad-spectrum antibiotics. Thus, the treatment of CAUTI in elderly patients should strictly abide by etiological examination before the use of antibiotics to avoid multidrug-resistant organism infections or complex infections caused by the unreasonable use of antibiotics. At the same time, our study provides a reference for the empirical application of antibiotics before etiological examination results.

In addition, we found that 70 of the 182 infected patients had more than one opportunistic pathogen during hospitalization (including 45 had two, 18 had three, and 7 had four or more). A total of 164 pathogens were detected in 70 patients, mainly E.faecium (25.61%), K.pneumoniae (17.68%), E.coli (14.02%), C.albicans (11.59%) and P.aeruginosa (6.71%).Analysis of the patients showed that 53 of the 70 patients with multi-pathogen infection were admitted to the geriatrics, neurology and rehabilitation departments for chronic diseases, and the length of hospitalization was generally long, with a minimum of 7 days and a maximum of 436 days, and the average hospitalization was 37.5 (22,61) days (median). In conclusion, a long hospital stay is the main risk factor for multi-pathogen infection in elderly patients.

Our study was divided into two groups, the CAUTI group and the non-CAUTI group, to investigate the clinical characteristics of elderly patients with indwelling urinary catheters. The results showed that fever was the clinical feature of elderly CAUTI patients, and 70% of the infected people had fever symptoms. It is well known that fever is a nonspecific symptom of infection. The judgment of CAUTI should be combined with clinical symptoms and signs in addition to indwelling urinary catheter time and urine culture results. Patients with indwelling urinary catheters have no obvious feeling of urinary symptoms, such as frequent urination and urgent urination, and most elderly inpatients have varying degrees of unconsciousness, increasing the difficulty of determining CAUTI. If the judgment is wrong, the optimal time for treatment may be missed. Therefore, in clinical diagnosis and treatment, when elderly patients with indwelling urinary catheters have fever symptoms, attention should be given to the identification of other infections that cannot be excluded from CAUTI determination because they are clinically deemed due to another recognized cause.

In addition, the detection of procalcitonin and urinary nitrite is also an auxiliary index commonly used in the diagnosis of CAUTI. Our analysis results show that compared with the group without CAUTI, these two tests are meaningful, but they have more advantages in determining procalcitonin in infection, with an abnormal rate of 83.52%, which can be considered one of the effective indicators for the diagnosis of CAUTI in elderly individuals.

We found that older patients with urinary retention or incontinence were more likely to develop CAUTI than those with normal urination function. Considering the high incidence of urinary retention and incontinence in the elderly [ 24 , 25 ], it is the main indication for indwelling urinary catheters in elderly patients, and it requires a long duration of indwelling. The degeneration of urinary tract mucosa and the decrease in local antibacterial ability in elderly individuals may increase the risk of CAUTI. Therefore, elderly patients with abnormal urination function should be taken as the key population for infection prevention and control.

Finally, we analysed the prognosis of CAUTI. We found that CAUTI could significantly affect the clinical outcome of patients, including prolonged hospitalization, increased hospitalization costs and increased all-cause mortality, which was consistent with related research conclusions [ 26 , 27 ]. In recent years, there have been many studies on CAUTI, but few studies have clarified the impact of adverse outcomes based on a large sample size. The results of this study provide a useful supplement to this. Our study showed that compared with the non-CAUTI group, the hospitalization days of the CAUTI group increased by 18 days, the total hospitalization cost increased by ¥18,000, and discharge all-cause mortality increased by 2.314 times. To save national medical resources, improve patient safety and reduce mortality, clinical doctors and nurses should pay more attention to the prevention, control and management of CAUTI. In daily work, guiding suggestions and prevention and control measures in national norms and expert consensus should be implemented.

There are several limitations to this study. First, our study was conducted in a single hospital, which limits the representativeness and extrapolation of results from a single center. Second, our study is a retrospective analysis with limited data, but it points out the direction for our future research. We will carry out a prospective study on this subject.

The situation of CAUTI in the elderly is not optimistic, it is easy to have one-person multi-pathogen infection, and the proportion of fungal infection is not low. Our study uses a large sample size to determine the risk factors different from other studies, providing a new idea for the prevention and control of aged CAUTI. Meanwhile, the clinical characteristics of aged CAUTI patients were analysed and summarized. It provides a reliable basis for its diagnosis and clarifies the adverse outcomes of CAUTI. These findings are important for preventing and controlling CAUTI in aged individuals.

Data Availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Catheter-associated Urinary Tract Infection

Urinary Tract Infection

American Type Culture Collection

Statistical Package for Social Science

Center for Disease Control

National Healthcare Safety Network

Hospital Information System

Laboratory Information System

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Acknowledgements

We thank the participants in the study.

This study was supported by the Discipline Promotion Project of the First Affiliated Hospital of Air Force Medical University (XJHL22D201).

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Li Shen, Huiying Sun, Xiaoyun Lu, Jing Zhang & Zhaoxu Yang

Department of Military Prevention Medicine, Air Force Medical University, Changle West Road, Xincheng District, Xi’an, Shaanxi, China

Department of information, The First Affiliated Hospital of Air Force Medical University, Changle West Road, Xincheng District, Xi’an, Shaanxi, China

Luguang Huang

Neurosurgical ICU, The First Affiliated Hospital of Air Force Medical University, Changle West Road, Xincheng District, Xi’an, Shaanxi, China

Neurological ICU, The First Affiliated Hospital of Air Force Medical University, Changle West Road, Xincheng District, Xi’an, Shaanxi, China

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LS designed and wrote the manuscript. LGH was responsible for obtaining data in the hospital’s HIS and LIS systems. LS and TF collected the data and completed the analysis. YW, LLS and XYL participated in patient recruitment and manuscript preparation. HYS and JZ participated in the diagnosis and review of infection cases. CPN and ZXY participated in the study design and data analysis. All authors reviewed the results and data analysis and contributed comments. All authors agreed on the final version for submission to the journal.

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Shen, L., Fu, T., Huang, L. et al. 7295 elderly hospitalized patients with catheter-associated urinary tract infection: a case-control study. BMC Infect Dis 23 , 825 (2023). https://doi.org/10.1186/s12879-023-08711-0

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What happened in the Kolkata rape case that triggered doctors’ protests?

Activists and doctors in India demand better safeguarding of women and medical professionals after a trainee medic was raped and murdered in Kolkata.

Activists and doctors across India continued to protest on Wednesday to demand justice for a female doctor, who was raped and murdered while on duty in a hospital in the eastern city of Kolkata.

Feminist groups rallied on the streets in protests titled “Reclaim the Night” in Kolkata overnight on Wednesday – on the eve of India’s independence day – in solidarity with the victim, demanding the principal of RG Kar Medical College resign. Some feminist protesters also marched well beyond Kolkata, including in the capital Delhi.

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While the protests were largely peaceful, a small mob of men stormed the medical college and vandalised property. This group was dispersed by the police.

This comes after two days of nationwide protests by doctors following the incident at RG Kar Medical College in West Bengal’s capital city. “Sit-in demonstrations and agitation in the hospital campus will continue,” one of the protesting doctors, identified as Dr Mridul, told Al Jazeera.

Services in some medical centres were halted indefinitely, and marches and vigils shed light on issues of sexual violence, as well as doctors’ safety in the world’s most populous nation.

What happened to the doctor in Kolkata?

A 31-year-old trainee doctor’s dead body, bearing multiple injuries, was found on August 9 in a government teaching hospital in Kolkata.

The parents of the victim were initially told “by hospital authorities that their daughter had committed suicide,” lawyer and women’s rights activist Vrinda Grover told Al Jazeera. But an autopsy confirmed that the victim was raped and killed.

Grover has appeared for victims in sexual violence cases in India in the past, including Bilkis Bano , a Muslim woman who was gang-raped during the 2002 Gujarat riots, and Soni Sori, a tribal activist based in Chhattisgarh state.

Thousands of doctors marched in Kolkata on Monday, demanding better security measures and justice for the victim.

On Tuesday, the Kolkata High Court transferred the case to the Central Bureau of Investigation (CBI).

The Federation of Resident Doctors Association (FORDA) called for a nationwide halting of elective services in hospitals starting on Monday. Elective services are medical treatments that can be deferred or are not deemed medically necessary.

On Tuesday, FORDA announced on its X account that it is calling off the strike after Health Minister Jagat Prakash Nadda accepted protest demands.

One of these demands was solidifying the Central Protection Act, intended to be a central law to protect medical professionals from violence, which was proposed in the parliament’s lower house in 2022, but has not yet been enacted.

FORDA said that the ministry would begin working on the Act within 15 days of the news release, and that a written statement from the ministry was expected to be released soon.

Press release regarding call off of strike. In our fight for the sad incident at R G Kar, the demands raised by us have been met in full by the @OfficeofJPNadda , with concrete steps in place, and not just verbal assurances. Central Healthcare Protection Act ratification… pic.twitter.com/OXdSZgM1Jc — FORDA INDIA (@FordaIndia) August 13, 2024

Why are some Indian doctors continuing to protest?

However, other doctors’ federations and hospitals have said they will not back down on the strike until a concrete solution is found, including a central law to curb attacks on doctors.

Those continuing to strike included the Federation of All India Medical Associations (FAIMA), Delhi-based All India Institute Of Medical Sciences (AIIMS) and Indira Gandhi Hospital, local media reported.

Ragunandan Dixit, the general secretary of the AIIMS Resident Doctors’ Association, said that the indefinite strike will continue until their demands are met, including a written guarantee of the implementation of the Central Protection Act.

Medical professionals in India want a central law that makes violence against doctors a non-bailable, punishable offence, in hopes that it deters such violent crimes against doctors in the future.

Those continuing to protest also call for the dismissal of the principal of the college, who was transferred. “We’re demanding his termination, not just transfer,” Dr Abdul Waqim Khan, a protesting doctor told ANI news agency. “We’re also demanding a death penalty for the criminal,” he added.

“Calling off the strike now would mean that female resident doctors might never receive justice,” Dr Dhruv Chauhan, member of the National Council of the Indian Medical Association’s Junior Doctors’ Network told local news agency Press Trust of India (PTI).

Which states in India saw doctors’ protests?

While the protests started in West Bengal’s Kolkata on Monday, they spread across the country on Tuesday.

The capital New Delhi, union territory Chandigarh, Uttar Pradesh capital Lucknow and city Prayagraj, Bihar capital Patna and southern state Goa also saw doctors’ protests.

Who is the suspect in the Kolkata rape case?

Local media reported that the police arrested suspect Sanjoy Roy, a civic volunteer who would visit the hospital often. He has unrestricted access to the ward and the police found compelling evidence against him.

The parents of the victim told the court that they suspect that it was a case of gang rape, local media reported.

Why is sexual violence on the rise in India?

Sexual violence is rampant in India, where 90 rapes were reported on average every day in 2022.

Laws against sexual violence were made stricter following a rape case in 2012, when a 22-year-old physiotherapy intern was brutally gang-raped and murdered on a bus in Delhi. Four men were hanged for the gang rape, which had triggered a nationwide protests.

But despite new laws in place, “the graph of sexual violence in India continues to spiral unabated,” said Grover.

She added that in her experience at most workplaces, scant attention is paid to diligent and rigorous enforcement of the laws.

“It is regrettable that government and institutions respond only after the woman has already suffered sexual assault and often succumbed to death in the incident,” she added, saying preventive measures are not taken.

In many rape cases in India, perpetrators have not been held accountable. In 2002, Bano was raped by 11 men, who were sentenced to life imprisonment. In 2022, the government of Prime Minister Narendra Modi authorised the release of the men, who were greeted with applause and garlands upon their release.

However, their remission was overruled and the Supreme Court sent the rapists back to jail after public outcry.

Grover believes that the death penalty will not deter rapists until India addresses the deeply entrenched problem of sexual violence. “For any change, India as a society will have to confront and challenge, patriarchy, discrimination and inequality that is embedded in our homes, families, cultural practices, social norms and religious traditions”.

What makes this case particularly prominent is that it happened in Kolkata, Sandip Roy, a freelance contributor to NPR, told Al Jazeera. “Kolkata actually prided itself for a long time on being really low in the case of violence against women and being relatively safe for women.”

A National Crime Records Bureau (NCRB) report said that Kolkata had the lowest number of rape cases in 2021 among 19 metropolitan cities, with 11 cases in the whole year. In comparison, New Delhi was reported to have recorded 1, 226 cases that year.

Prime Minister Modi’s governing Bharatiya Janata Party (BJP) has called for dismissing the government in West Bengal, where Kolkata is located, led by Mamata Banerjee of All India Trinamool Congress (AITC). Banerjee’s party is part of the opposition alliance.

Rahul Gandhi, the leader of the opposition in parliament, also called for justice for the victim.

“The attempt to save the accused instead of providing justice to the victim raises serious questions on the hospital and the local administration,” he posted on X on Wednesday.

Roy spoke about the politicisation of the case since an opposition party governs West Bengal. “The local government’s opposition will try to make this an issue of women’s safety in the state,” he said.

Have doctors in India protested before?

Roy explained to Al Jazeera that this case is an overlap of two kinds of violence, the violence against a woman, as well as violence against “an overworked medical professional”.

Doctors in India do not have sufficient workplace security, and attacks on doctors have started protests in India before.

In 2019, two junior doctors were physically assaulted in Kolkata’s Nil Ratan Sircar Medical College and Hospital (NRSMCH) by a mob of people after a 75-year-old patient passed away in the hospital.

Those attacks set off doctors’ protests in Kolkata, and senior doctors in West Bengal offered to resign from their positions to express solidarity with the junior doctors who were attacked.

More than 75 percent of Indian doctors have faced some form of violence, according to a survey by the Indian Medical Association in 2015.

What happens next?

The case will now be handled by the CBI, which sent a team to the hospital premises to inspect the crime scene on Wednesday morning, local media reported.

According to Indian law, the investigation into a case of rape or gang rape is to be completed within two months from the date of lodging of the First Information Report (police complaint), according to Grover, the lawyer.

The highest court in West Bengal, which transferred the case from the local police to the CBI on Tuesday, has directed the central investigating agency to file periodic status reports regarding the progress of the investigation.

The FIR was filed on August 9, which means the investigation is expected to be completed by October 9.

Bengal women will create history with a night long protest in various major locations in the state for at 11.55pm on 14th of August’24,the night that’ll mark our 78th year as an independent country. The campaign, 'Women, Reclaim the Night: The Night is Ours', is aimed at seeking… pic.twitter.com/Si9fd6YGNb — purpleready (@epicnephrin_e) August 13, 2024

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Deadly Landslides in India Made Worse by Climate Change, Study Finds

Extreme rainfall made 10 percent heavier by human-caused climate change triggered landslides that killed hundreds, according to a new study.

By Austyn Gaffney

A sudden burst of rainfall on July 30 caused a cascade of landslides that buried hundreds of people in the mountainous Kerala region of southern India.

That downpour was 10 percent heavier because of human-caused climate change, according to a study by World Weather Attribution, a group of scientists who quantify how climate change can influence extreme weather. Nearly six inches, or 150 millimeters, of rain fell on soils already highly saturated from two months of monsoon and marked the third highest single-day rain event on record for India.

“The devastation in northern Kerala is concerning not only because of the difficult humanitarian situation faced by thousands today, but also because this disaster occurred in a continually warming world,” said Maja Vahlberg, a climate risk consultant at the Red Cross Red Crescent Climate Centre. “The increase in climate-change-driven rainfall found in this study is likely to increase the number of landslides that could be triggered in the future.”

In a state that is highly prone to landslides, the Wayanad district is considered the riskiest part. As of Tuesday, at least 231 people had died and 100 remained missing.

The Kerala landslides were the second extreme landslide event in July, following one in Ethiopia that killed 257 people. July was the second-worst month on record, after July 2019, with 95 landslide events that caused 1,167 fatalities , according to data maintained by Dave Petley, the vice-chancellor of the University of Hull. Together, they caused roughly one-third of the more than 3,600 deaths resulting from some 429 fatal landslides recorded this year, Dr. Petley said in an email.

Already, 2024 is an outlier, Dr. Petley posted to The Landslide Blog on Tuesday . He wrote that he could “only speculate on the likely underlying reasons for this very high incidence of fatal landslides,” but “the most likely cause continues to be the exceptionally high global surface temperatures, and the resultant increase in high intensity rainfall events.”

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