Responses to the public consultation

No response to this question.

Respondent 3 feedback

Noted some links to not be working or pages have been removed (in the flowcharts and text: sampling).

Response: The website with the information on urine sample collection was removed, we have removed this link for now and will look for another resource that can be referred to.

Respondent 4 feedback

A quick ref guide in PDF format should not be 78 pages long.

Response: The 3 tools themselves are only 1 page each. The text resource provides accessible text, references and rationale for the recommendations, which are necessary in case the users would like more information.

Respondent 5 feedback

Respondent 5 details

This toolkit is for uncomplicated UTI but there is no clear definition of whom this excludes specifically: this needs to be prominent somewhere for users, as I have seen this toolkit being used in patients with complicated UTI many times in practice.
It was not clear on the website what patient involvement there was in the production/review of this toolkit, can this be included on the website when published?

Response:

We have included further text and references in the target groups section to clarify groups where complicated UTI needs to be considered.
Patient representatives were included as part of the steering group who oversaw and contributed to the review and update of this resource. Their names are roles are now acknowledged as part of steering group at the end of the resource.

Respondent 6 feedback

Respondent 6 details

The national plan for AMR 2024 to 2029 refers to utilisation of improved diagnostics within the executive summary: With reference to the diagnostics used for UTI detection the current guidelines still utilises old technologies such as dipsticks and culture. Dipsticks are of limited use in accurately diagnosing the presence of UTI, culture takes approx. 2 days for a result to be reported, and a large percentage of cultures report mixed growth with no clinically useful information provided. There is now rapid accurate molecular technologies available that detect specific pathogens within 35 minutes, providing ‘‘a rule in: rule out’’ result for UTI with 85% sensitivity. Such technologies should be incorporated into the guidance. one such technology is The Lodestar Assay System manufactured by Llusern Scientific.

Response: At this point of the review, we cannot endorse specific rapid diagnostic tests for use in UTIs within the UK. However, we will follow up with agencies who have this remit and update the diagnostic guidance once they are recommended for use within the NHS. This includes NICE, who recently reviewed this technology as part of its Point-of-care tests for urinary tract infections to improve antimicrobial prescribing: early value assessment (HTE7).

Respondent 7 feedback

Audience and target group: UTIs do still present to A&E/walk-in/urgent treatment centres; could this group of prescribers be named in second bullet point?
‘Covering acute uncomplicated infections in adults, older patients with urinary symptoms and children’ – reword – reads as if treating older patients with urinary symptoms and older patients with children? Also then says children not covered by this guideline?
In text summary of diagnostic decision tool – ‘It will be suitable for some women aged over 65 years in the community setting (refer to Audience and target group above).’ – link should point to ‘Aims and implications’?

Response:

The literature searches for these resources did not include urgent care, A&E or secondary care settings, so we are unable to include them as target groups.
This was a typing error, and children will be removed from the guidance.
This has been noted and the link will be updated.

Respondent 8 feedback

As ever, this is a generally helpful document that is well referenced and helpful.

Response: Thank you for the feedback.

Respondent 9 feedback

Respondent 9 details

The tools are useful and easy to use, they contain relevant diagnostic information.

Response: Thank you for the feedback.

Respondent 10 feedback

I’m sure this is required in the fullness of the guidance governance, but could it not be at the end for those few front-line clinicians who have the time, I should imagine that most using this, especially during a consultation with a patient will want the relevant guidance to be most prominent.
A quick reference tool should not be 78 pages long. This makes it unusable in the real world, call that document something different, separate out the distinct flowcharts, cut the superfluous non-UTI detail and have appendixes of more detail for those with the time or inclination.

Response:

Thank you for your comments. By using the flowcharts or the contents links on the left-hand side of the page, the aim is that users can skip to the information that is most relevant in that consultation.
In the updated tool we have 3 distinct flowcharts that can be downloaded separately from the full text which will enable a quick reference for prescribers. The text allows for users with assistive technology to access the content in the flowchart and obtain more information if desired. The majority of the text is currently in the references and rational appendixes, which aligns with what you suggest.

Respondent 11 feedback

Good clear update, relevant changes identified with reasoning and links to appropriate pages such as UTI in under 16-year-olds.

I like the new format and when it is published, I will update colleagues and replace the previous algorithms with the new ones.

Response: Thank you for the feedback.

Respondent 12 feedback

It does not look like even for the uncomplicated mild UTI that there is advice regarding self-treatment for the first 3 days.

Response: Thank you for the feedback. This guidance does not cover antimicrobial management however it does link to the respective NICE guidance which specifies treatment duration.

Respondent 13 feedback

They all look very good, easy to use, good with numbered boxes and colours and there’s all the info needed on there.

Response: Thank you for the feedback.

Respondent 14 feedback

NG12 recommends an urgent suspected bladder or renal cancer referral for those aged 45 and over, with non-visible haematuria that persists or recurs after successful treatment of urinary tract infection.

NG12 recommends an urgent suspected bladder cancer referral in those aged 60 and over with haematuria (non‑visible and unexplained) with dysuria or raised white cell count on a blood test.

Research suggests there may be missed opportunities for more timely detection of bladder cancer and commonly bladder cancer patients experience a long diagnostic interval (1, 2). The most common symptom of bladder cancer (occurring in around 80% of patients) is haematuria (3). Evidence has also reported that presentation with recurrent UTI is associated with diagnostic delays (2). As this symptom is also present with common, benign conditions, it makes recognition and assessment more challenging in primary care. There are other challenges to early recognition of bladder or renal cancers, as UTIs as often treated either by pharmacists or via telephone consultations, which may reduce likelihood that GPs are aware of the full patient history and contribute to missed diagnostic opportunities.

Urine culture results take a few days to receive, so many UTIs that are diagnosed in primary care are ‘presumptive UTIs’. Evidence has demonstrated patients with presumed UTIs were at an increased risk of experiencing potential missed diagnostic opportunities, with evidence of inadequate clinical examination, repeated antibiotic prescribing without review or referral and lack of communication of test results (4). Clinician awareness of at-risk groups needs to improve in order to reduce these missed diagnostic opportunities.

Evidence suggests that these challenges are particularly evident in women where occurrence of urinary tract infections is higher. Women are also more likely to be diagnosed with bladder cancer via an emergency route and to experience worse survival, often attributed to delays in investigating haematuria.

Key messages for health professionals could be incorporated into the diagnostic tools, such as:

Even a single episode of haematuria (both visible and non-visible) should be investigated and, if clinically appropriate, referred. 

Haematuria often presents intermittently, look back at patient history and ask your patient to be vigilant for recurrence  

Bladder cancer is linked to UTI symptoms such as urinary urgency or dysuria (burning when peeing). Ask your patients about their UTI history and request a follow-up after UTI treatment. 

Prostate cancer:

NG12 suggests considering a prostate-specific antigen (PSA) test to investigate for prostate cancer in men with symptoms associated with UTI, such as lower urinary tract symptoms (nocturia, urinary frequency, hesitancy, urgency or retention in men) or haematuria.

Evidence demonstrates that lower urinary tract symptoms (LUTS) are the most prevalent type of symptoms in people diagnosed with prostate cancer. However, LUTS are very common as men age and are associated with many benign conditions, including UTI, making identification challenging. (6) The causal relationship between LUTS and prostate cancer is not clear (7) . Many people presenting with LUTS may be diagnosed with clinically insignificant prostate cancer, also known as overdiagnosis (diagnosis of prostate cancer that would never have gone on to cause harm in a person’s lifetime).

It may be worth noting in the diagnostic tool that urological symptoms associated with UTIs can also be suggestive of potential prostate cancers.

Gynaecological cancers:

NG12 recommends considering direct access to ultrasound for those with haematuria (visible) with low haemoglobin levels or thrombocytosis or high blood glucose levels or unexplained vaginal discharge in women 55 and over, for endometrial cancer.

CA125 test would be warranted in women, especially aged 50 years or over, with urinary urgency or frequency (increased and persistent or frequent – particularly more than 12 times per month)

It may be worth noting in the diagnostic tool that urological symptoms associated with UTIs, including haematuria, urinary urgency or frequency, can also be suggestive of potential gynaecological cancers.

Response:

Thank you for your comments.

This is an important issue, and we discussed this as at length with the steering group.

Because these diagnostic tools are for use with people presenting with non-recurrent UTI in primary care, it was felt that it would be reasonable to expect that haematuria was related to this infection if a clinician felt the diagnosis of non-recurrent UTI was appropriate. To make this more visible in the tools, we have added a statement about those with recurrent UTI being excluded at the top of each flowchart and in each section of web text.

Additionally, in the flowchart for women under 65 years, we have linked to the NICE guidelines on suspected cancer for recognition and referral if patients present with haematuria and has met fewer of the noted diagnostic symptoms/signs for urinary tract infection.

To further highlight the need to consider cancer when assessing patients in primary care settings, we have included the following statement in each section of the web text: Refer people with unexplained or persistent haematuria or suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral.

Respondent 15 feedback

The introduction states that these pathways are in agreement with NICE and NICE CKS. I presume you have had comments from CKS as they are different from NICE, as you know.
We would welcome more emphasis, and early on, on the need for person-centred approach and truly informed shared decision making here. Currently, the pathways may be perceived as very ‘done to’ rather than ‘done in discussion with the person’, for example in the first pathway you can get all the way to step 7 before there is any mention of involving patients in decision making. You could overcome this easily with reference early on to the 3-step model of shared decision making, as outlined in the NICE SDM guideline see rec 1.1.13 Recommendations, Shared decision making, Guidance, NICE)
Overall this will be a welcome pathway and helps with the AMS messages.

Response:

Thank you for your comments. We have sent this to CKS and they let us know that they would circulate the resource for feedback but we haven’t received a response. As they have not provided input, we have removed them.
We have developed some text on the 3-step model of shared decision making and put this near the top of the guidance for easy reference.
Thank you for the feedback.

Respondent 16 feedback

The only thing I had to flag was our early value assessment on tests for UTI.

As the truly rapid tests (some slower ones were included that were judged not fast enough to influence prescribing) weren’t yet CE marked the committee couldn’t recommend them, but we are keeping an eye on the area. It doesn’t need to be referenced in the pathway but is helpful to know the technologies and developments are on NICE’s radar.

Response: Thank you. We will regularly review this for updated recommendations.

Respondent 17 feedback

I am writing to you today about the open consultation for the Urinary tract infection (UTI): diagnostic tools for primary care providers. We understand the critical importance in preventing the emergence of antibiotic resistance. As well as the change of global guidelines, encouraging appropriate usage of antibiotics and alternative effective non-antibiotic treatments, as underlined by the UK antimicrobial resistance strategy.

UTIs account for 25 to 40% of antibiotic consumption in primary care, therefore, play a major role in driving antibiotic resistance. The increase in antibiotic resistance especially towards Escherichia coli has increasingly complicated treatment options for UTIs, leading to less viable and effective oral antibiotic treatments. Dysuria is one of the most common symptoms associated with UTIs, and a main driver for early antibiotic intervention. The risk of uncomplicated UTI leading to pyelonephritis is very low and therefore, the management of pain relief leaves time for the immune system to react. Early initiation of antibiotic therapy can be inappropriate and lead to increased antibiotic usage and waste. Therefore, unnecessary use of antibiotics must be considered alongside antibiotic sparing strategies. Curegevity are in the process of licensing a non-antibiotic treatment option for recurrent UTI and cystitis. The medicinal product contains the active substances Methenamine Hippurate and Phenyl Salicylate. Methenamine Hippurate is one such non-antibiotic treatment, which is hydrolysed to formaldehyde in acidic environments such as the distal tubules of the kidney. Formaldehyde is bactericidal and works by denaturing bacterial proteins and nucleic acids. Methenamine Hippurate was not historically considered in the treatment of UTI because it requires an acidic urine for its antimicrobial activity, and it is ineffective for upper urinary-tract infections. Considering the recent ALTAR study outcomes NICE surveillance have updated NG112 stating the following:

“Prescribing methenamine Hippurate The BNF confirms that methenamine Hippurate is indicated in patients with recurrent uncomplicated lower UTIs. However, the BNF also highlights that methenamine Hippurate requires acidic urine for its mode of action, and as such is often considered less suitable for prescribing in primary care.

Antimicrobial stewardship:

Widespread use of antimicrobials has been linked to microbes such as bacteria and viruses changing and becoming resistant to treatment. It is therefore important to reduce the use antimicrobials, particularly antibiotics, to protect our health and the health of future generations. Methenamine Hippurate is a urinary antiseptic drug used for the prevention of recurrent UTIs. If widely used it would act as an alternative to low-dose prophylactic antibiotics for recurrent UTIs (rUTIs), as recommended by the NICE guideline, and may contribute to the aims of antimicrobial stewardship. “The outcome of the surveillance as confirmed by the topic experts is to now update guidelines to include pharmacological treatments of UTIs with methenamine Hippurate. However, Methenamine Hippurate requires acidic conditions to be hydrolysed into formaldehyde, some UK clinicians’ resort to prescribing Vitamin C (Sorbic acid) alongside methenamine to acidify urine further and drive the hydrolyzation reaction of Methenamine, thereby increasing therapeutic efficacy.

Curegevity current product development aims to enhance the activity of methenamine Hippurate by the synergistic action of phenyl salicylate. The use of the methenamine and phenyl salicylate combination is widely used in the US for the treatment of rUTI and UTI prophylaxis. However, this combination is not currently licensed in the UK. The active ingredients work synergistically, as the formaldehyde (hydrolysed methenamine) and Phenolic acid act as bactericidal and fungicidal agents. The salicylic acid derivative acts as a local anti-inflammatory, analgesic with antipyretic effects, by inhibiting activity of cyclooxygenase, an enzyme that activates one of the pathways of Arachidonic acid metabolism. The end products of this process are prostaglandins, prostacyclin and thromboxanes, which belong to the transmitters of inflammatory processes. Inhibition of action cyclooxygenase leads to a reduction in the severity of inflammatory symptoms resulting in the targeting of dysuria and inflammation. Furthermore, salicylic acid has a typical pKa of 3.5 which would further contribute to driving towards an acidic urine environment favouring methenamine hydrolysation. Other components of this new formulation include phenolic acids which are known to have beneficial use in a wide variety of urological diseases. Due to its inherent antimicrobial, bacteriostatic and fungicidal activity. The use of phenolic acids in rUTI and UTI prophylaxis would not be considered as antibiotic consumption.

To summarise, in the absence of UTI infection diagnosis the continued use of empirical antibiotics is not scientifically justified, nor does it favour targeted antibiotic use and can contribute towards antibiotic resistance. Non-antibiotic, pharmacological interventions such as methenamine Hippurate can offer in-vivo antiseptic treatment for UTIs whilst reducing unnecessary antibiotic consumption. Curegevity methenamine/phenyl salicylate antiseptic/anti-inflammatory/analgesic combination therapeutic approach would offer a comprehensive, robust pharmacological approach which would minimise the risk of treatment failure (total indiscriminate microbial lethality) and non-selective lethality, eliminating the emergence of antibiotic resistance.

As stakeholders and with active interest in antimicrobial stewardship, we would be happy to discuss our product development, please contact us for any questions. We would appreciate any feedback, thank you for your time.

References:

Frimodt-Møller, N. and Bjerrum, L. (2023) ‘Treating urinary tract infections in the era of antibiotic resistance’, Expert Review of Anti-infective Therapy, 21(12), pp. 1301–1308. doi:10.1080/14787210.2023.2279104.
Harding, C. and others (2022) ‘Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women: Multicentre, open label, randomised, non-inferiority trial’, BMJ [Preprint]. doi:10.1136/bmj-2021-0068229. 3.Harding, C.K. and others (2021) ‘Alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women (Altar): A multi-centre randomised, non-inferiority trial’, SSRN Electronic Journal [Preprint]. doi:10.2139/ssrn.3839397.
McNulty, C.A. and others (2019) ‘Public understanding and use of antibiotics in England: Findings from a household survey in 2017’, BMJ Open, 9(10). doi:10.1136/bmjopen-2019-030845.

Response: Thank you - the flowcharts are meant to guide diagnostic decision making and do not include recommendations on therapeutics or medications used for prevention or treatment of UTI. We do link to NICE guidance for management of UTI, which includes recurrent UTI and will align with any relevant updates they make around methenamine use that are specific to UTI diagnosis in non-recurrent UTI.

Respondent 18 feedback

I only looked at the diagnostic tool for women under 65 and I felt that the updates made the figure clearer and more visually accessible.

Incidentally, I did just publish this paper exploring the diagnostic tool if you or the team are interested.

Response: Thank you for sharing your exploratory research, but as you haven’t stated an action or recommendation to make through this consultation, we have not been able to action a change.

Respondent 19 feedback

Overall, It is clear and useful, and we are pleased to see that pregnancy has been highlighted. The changes to previous well-constructed pathways are limited. Additionally, the inclusion of the text and algorithms are useful. However, in practice, most clinicians are using NICE CKS as a guide.
This is useful for many Additional role staff in General Practice but could also be used within the context of Pharmacy First and would include Community Pharmacy too.
It is important to provide some acknowledgment of the fact that it is not always possible to send a urinary sample off e.g. if a person cannot provide one, or if its too late for primary care transport of specimens to the hospital lab as at present you will be sent several refrigerated overnight specimens.
RBCs: it is lamentable that these were removed from lab results as they were an excellent past sign for secondary pathology. The microhaematuria picked up on stick testing or macrohematuria in conjunction with positive UTI diagnosis therefore needs a statement to ensure it is cleared in x days post treatment to rule out haematuria and therefore a referral. The guidance must include other eventualities and not be exclusive to UTI.
Put sending sample at the start and interpretation at the end (as is)
SaIt would be useful to cover: the rationale for antibiotic choice (as NICE publishes only ‘quick guidance’); the differences between use for Lower and Upper UTI; the significance of some antibiotics concentrating in the bladder (especially nitrofurantoin, trimethoprim) and thus ‘overperforming’ as treatment choices for cystitis (Gupta, Hooton, Stamm 2001 Ann Intern Med); and the importance of preserving wider spectrum antibiotics for more severe infections.

Response:

Thank you for your comments. These algorithms are cited by CKS in their guidance so should align with the recommendations provided.
We have worked with the Pharmacy First team to align the pathway as much as possible for women under 65 years.
We have amended the wording so that we aren’t stating that a sample must be sent.
This resource is specific to UTI diagnostic guidance, and it is outside the remit of the tool to comprehensively cover cancer management. We have added links throughout the guidance to prompt clinicians to refer to NG12 to the rapid referral for cancer pathway if there is unexplained haematuria or other reason to suspect cancer.
This has been noted, thank you.
Including a range of information regarding UTI management (for example, the rationale for antibiotic choice and the differences between upper and lower UTI) is beyond the remit of this resource. This information is covered in the NICE management guidance which we have linked to.

Respondent 20 feedback

I am writing with reference to the Open Consultation paper on the Diagnosis of urinary tract infections: quick reference tools for primary care.

In 2000 I was diagnosed with non-invasive carcinoma in the bladder. A course of Mitomycin and a course of BCG instillation followed together with several TURBT procedures. In May 2003, aged 48, I underwent a radical cystectomy and construction of an ileal neobladder. This was considered necessary due to rapid tumour growth and maturity and lengthening waiting lists for TURBTs.

After the RC I found I was unable to empty the neobladder without intermittent self-catheterisation, and the neobladder was completely continent.

From January 2004 onwards I experienced repeated UTIs that were treated with various antibiotics after lab work. On occasions the lab reported contamination of the sample even though I was using hygienic methods when catheterising. It then became apparent that the primary care surgery were dipping the urine and decanting it from one container to another. I discussed this with my Urologist, and he confirmed that my sample should not be dipped as the results would not be helpful due to the presence of mucus from the ileal neobladder.

In 2009 I started to experience incontinence, and this has got steadily worse over the last 15 years. Despite this I continued to experience UTIs and in 2012 had 3 bouts of urosepsis resulting in hospitalisation for the final bout following a false negative lab result. Damage was noted to the right kidney by ultrasound.

Since then, we have moved, and I am now with a different Urology Department and different Primary Care Provider.

In 2016 my current Urologist proposed that I take a prophylactic Co-amoxiclav 500/125 once a day. This has been fairly successful, and I now only experience occasional UTIs that are not responsive and require a course of nitrofurantoin. If diagnosis is not completed in a timely manner, I experience ileitis in the neobladder wall which is extremely painful and can last for up to 10 days.

Since the current diagnostic states that urine should be dipped, my current primary care surgery is insisting on dipping and decanting prior to sending samples to the lab. The new proposed guidance will solve this problem as I am now aged 69.

However, I do feel that people with continent and incontinent urinary diversions should be a separate group in the Diagnostic Tool and that it needs to be recognised that women with continent neobladders who self-catheterise are likely to experience repetitive UTIs due to non-flushing of the urethra by urine. In my experience primary carers see too few cases to develop a robust protocol themselves.

Response: Thank you for your comments. They have really highlighted the issues that those who have complicated UTIs can experience. We have added additional text to clarify that people who with a structural or functional differences of the urinary tract would belong to the complex UTI group. These algorithms should not be used for those with recurrent UTI or UTIs at high risk of complication (complicated UTI) because of the additional considerations that need to be factored into the clinical decision-making process.

Question 3

Diagnostic decision tool for women (under 65 years) with suspected urinary tract infection: algorithm, web text, and rationale

Accepted Answer

Respondent 1 feedback

Respondent 1 details

Really well set out and useful but it is a bit busy to make it a quick tool.

Response: Thank you for the feedback. We have tried to make the flowcharts as simple to follow as possible.

Respondent 2 feedback

No feedback to this question.

Respondent 3 feedback

If suspecting Sepsis then patient most likely will require IV abx in acute trust. Should Pyelonephritis and Sepsis flow chart boxes be separate??
What is definition of rational for at ‘risk of antibiotic resistance’ for sending a culture?
Step 6a) link: page has been removed.
UTI (Lower) prescribing guidance indicates to take culture for sensitivities, this contradicts Step 6a) on taking culture. How do you know if pathogenic resistant if not sampled? Is this linking in with AMR action strategy 2024 to 2029?

Response:

Removing the delineation between the 2 boxes was a design change. We will separate the sepsis and PN boxes again
Risk factors for resistance are outlined in the text within the ‘Sending urine for culture and interpreting results in all adults’ section. We will hyperlink into this section in the text so that users can refer if needs be.
Thank you – it appears this page was removed by NHS digital. We will look for another reference to link these to.
For women at risk of resistance we suggest taking a urine sample. However, for women with a low risk for resistance and presenting for non-recurrent lower UTI a sample should not be necessary. This aligns with NICE guidance for lower UTI management, where it states in the evidence summary: Based on evidence and experience, the committee agreed that either a back-up antibiotic prescription or an immediate antibiotic prescription could be prescribed for non-pregnant women with a lower UTI. The committee discussed that sending a urine sample for culture and susceptibility testing is not usual practice in most young, non-pregnant women with a first lower UTI.

Respondent 4 feedback

No feedback to this question.

Respondent 5 feedback

In the box numbered 1. Urethritis is part of cystitis (the first step in UTI establishing) so having this as an ‘exclusion’ of UTI criteria is problematic for me. Given that post-intercourse UTI is common in younger women, having ‘inflammation post sexual intercourse’ is potentially excluding women with genuine UTI. The only difference between what has previously being called ‘urethral syndrome’ and cystitis, is the culture threshold used (Stamm and others doi: 10.1056/NEJM198008213030801, so I disagree with having urethritis as a standalone exclusion box. The STI risk box and vaginal discharge should capture most patients with true urethritis due to non-UTI causes.
The box below 6b in the flowchart and the wording of ‘‘send urine for culture to confirm diagnosis’’ – the standard urine culture offered by routine diagnostic laboratories in the UK is not sensitive enough to be used to confirm or exclude the diagnosis of UTI. The fact that most laboratories use 10⁴ or 10⁵ cfu/ml is acknowledged in the section on ‘Interpreting Urine Culture Result if a UTI is Suspected’ but this is not reflected in the content of the flowchart making it unlikely that users will realise that the standard thresholds used are not sensitive enough in symptomatic patients. The current wording misleads the user if the culture result is ultimately reported as ‘no significant growth’, when patients may in fact have dysuria, positive LE plus a uropathogen with colony counts of 10² or 10³ cfu/ml. This often leads in practice to women being told that despite UTI symptoms and pyuria, they do not have a UTI based on a standard urine culture result.
The wording ‘UTI equally as likely to other diagnosis’ is very confusing - what other diagnoses are being eluded to? For example, if a women has dysuria and pyuria (LE on dipstick) then what other diagnosis are you expecting GPs/users to consider if the (insensitive) culture comes back ‘no significant growth’? This is a very frequent call we get from GPs to microbiology, and my response if that the culture is not a sensitive diagnostic test and if they have dysuria (the strongest symptom indicator in the cited study) then the standard culture is not sensitive enough to exclude and so treatment should be given.
The study (Little and others 2010) that Table 1 (and this algorithm) is based on uses a threshold of >=10³ cfu/ml to classify patients based on their symptoms and urine dipstick correlation with culture results. This is very well-designed study, but in the UK this culture threshold is not routinely used/available. It is misleading as users are unlikely to notice that the data in this table relates to a lower cfu/ml threshold than the test that is routinely available to them in practice. The authors conclude that the NPV of dipstick is poor, and in symptomatic women with a negative urine dipstick, 25% of women still have a UTI“ can this be acknowledged in the box 6c rather than saying ‘reassure UTI less likely and consider other diagnosis’, as UTI is still the diagnosis in 1 of 4 of these patients.

Response:

Thank you for your comments. We agree that this risks not diagnosing women with a UTI who have symptoms immediately after sexual intercourse. Not all patients with urethritis are going to want to go down the STI route. We will review the wording regarding urethritis and mention urethritis caused by irritation or inflammation (non-UTI causes).
We have changed the wording to say inform diagnosis. We have also added additional information regarding the lower colony counts to the sampling section of the diagnostic tool.
We discussed this with users and feedback was that most people who work within primary care would understand what is meant by ‘UTI likely’ and ‘UTI less likely’ etc. We feel that adding additional information will take away from the usability of the guidance.
Although antibiotic management is not an explicit recommendation for those who fall into the UTI less likely category, the pathway then directs users to provide self-care and safety-netting advice using TARGET UTI leaflet and involve patients in decisions about management options. This would allow for further discussion of options if a woman still has significant concerns about not receiving an immediate antibiotic for her symptoms.

Respondent 6 feedback

Respondent 6 details

There is a need to include rapid accurate pathogen detection tools, such diagnostic systems exist and are commercially available in the UK. The lodestar (Llusern Scientific) could be used for the detection of the 6 most common pathogens present in UTI’s in 35 mins. This should be used in addition to dipsticks and culture. This particular system along with others is currently being evaluated via the Toucan Study funded by NIHR in Oxford.

Response: At this point of the review, we have not found evidence to endorse an alternative rapid diagnostic test for use in UTIs within the UK. However, we will communicate with agencies who have this remit and update the diagnostic guidance once they are recommended for use within the NHS.

Respondent 7 feedback

?’Think Sepsis’ should come before exclude vaginal and urethral causes as more significant condition to exclude.
https://www.nhs.uk/common-health-questions/infections/how-should-i-collect-and-store-a-urine-sample/ - link removed from NHS site…multiple links to this page
‘It will be suitable for some women aged over 65 years in the community setting (refer to Audience and target group above).’ - the link should point to ‘Aims and implications’.
RBCs only present - urine should be sent for culture - applies to 6a. and 6c.

Response:

Thank you for the comments. This was discussed with the steering group and it was agreed that it is more appropriate for users to consider sepsis and pyelonephritis second as patients presenting with sepsis symptoms will likely go to A&E rather than to a primary care provider. However, as it is high up in the pathway, we don’t feel that it could be easily missed and clinicians will recognise that this needs to be considered as part of the overall messaging around sepsis throughout the pathway.
Thank you for identifying this. NHS Digital have removed the guidance that has been referred to and we are working with NHSE to find another link to include.
This has been noted and will be amended accordingly.
Regarding 6a., we don’t recommend using dipsticks in this group as they are strongly symptomatic for a UTI and this flowchart excludes those with recurrent UTIs. We have added additional text to the different flowcharts and web text to try and make this more evident. For 6c., the suspected cancer rapid referral will require a urine culture to be sent if there are only RBCs, so that’s covered in that respect. Patients are also covered if they’re pregnant. Therefore, we don’t feel that any additional information needs adding to these sections.

Respondent 8 feedback

As ever, this is a generally helpful document.

Response: Thank you for the feedback.

Respondent 9 feedback

What is the rationale for prescribing antibiotics before the result of the urine culture?
The diagnostic tool excludes women with recurrent UTIs, it would be helpful to signpost clinicians to national guidance.
Also, the hyperlink for obtain urine sample does not work as the page has been removed.

Response:

Thank you for your comments. It can be difficult to send symptomatic patients away without treatment, so we use the word ‘consider’ regarding the prescription of antibiotics to cover this. This should be assessed on an individual basis depending on symptom severity.
Noted, thank you. To keep our references consistent, we have linked to the NICE guidance for recurrent UTIs. However, as this is cited by the CKS guidance hopefully will be supported by both.
Thank you for identifying this. NHS Digital have removed the guidance that has been referred to and we are working with NHSE to find another link to include.

Respondent 10 feedback

Respondent 10 details

This is too wordy, you are a third of the way down the flowchart before you start UTI based guidance. Accepting that you need to be clear that the guidance is not for other things (all of boxes 1, 2, and 3) but again front-line clinicians will have done this before searching for the guidance. You could still signpost to other relevant differential diagnoses but in a much briefer way.

Response:

The flowchart is only one page so it is expected that users will focus on the sections that are most relevant to them once they are familiar with the tool. It is important that new users are reminded to exclude other infections as this is a key area of improving antimicrobial management for UTI symptoms.

Respondent 11 feedback

The different colours make it clearer. I like that the sepsis concerns are in a red colour.

Response: Thank you for the feedback.

Respondent 12 feedback

I’ve looked at the flow charts and I like those – what I hate is lots of waffle when reading guidelines. It does feel like there’s a lot of work being done on UTIs currently.

I presume this will be linked into the Pharmacy First guidance as apparently, we can send all our under 65-year-old women with uncomplicated to local practices participating in Pharmacy First. https://www.target-webinars.com/wp-content/uploads/2016/08/UTI-Leaflet-V16.pdf

Response: Thank you for the feedback. The Pharmacy First Patient Group Directions (PGDs) were developed in alignment with the flowcharts, and we will work to ensure that we communicate with them to incorporate any relevant updates that are made as an outcome of this review.

Respondent 13 feedback

On under 65 flowchart (and prob over 65) BOX 2’s asterisk ‘*to box below’ would be neater to say, ‘see box 8 below’ and add an 8 to the box.

Response: This has been noted, thank you. We would do this, but the numbers align to steps in the web text and the signs of pyelonephritis are connected to the step 2 box.

Respondent 14 feedback

The audience and target group (section, second bullet) includes children; however, the following paragraph then excludes children (inconsistent).
As above (step 7) includes information about involving patients but doesn’t make any reference to the NICE PDA on cystitis could we suggest a link?
The pathway presents some issues:
a. The pathway says do not treat ASB, however, our NICE guideline states do not routinely treat, the difference is (as per the NICE guideline evidence review) that there are occasions when it is appropriate to treat including preoperatively where there are expected mucosal breaches.
b. Step 1 has 2 issues, are other clinician experts ok with routing those with vaginal discharge away from treating as a UTI – 1 in 5 (20%) will have an infectious cause according to the evidence presented. Just so long as this has been considered
c. Secondly, sexually transmitted diseases are routed away from the UTI guidance, but this time the issue is that it is done before consideration of sepsis. Syphilis (for example) is a known cause of sepsis. It appears that perhaps the consideration of sepsis should come as the first step in the pathway (as it is for the other diagnostic pathways)? You could then cross refer to the sepsis guidance (and it may well help to allay concerns of Matt IK and so on, who are rightly concerned that non-treatment of infections may result in sepsis in a proportion of people.

Response:

Thank you for the comments. This was a typing error, and children will be removed from the guidance.
This has been noted and we will add a link to PDA the background section. The target leaflet for women under 65 years that is linked to in the text was also developed to support shared decision making for women under 65 years.
(a) We will amend this to state “do not routinely treat ASB” and will link to the NICE evidence review.
(b) This was considered, and we have ensured that the users are guided to ensure safety netting guidance in case other management options to not resolve the symptoms.
(c) This was discussed with the steering group, and it was agreed that it is more appropriate for users to consider sepsis and pyelonephritis second as patients presenting with sepsis symptoms will likely go to A&E rather than to a primary care provider. However, as it is high up in the pathway, we don’t feel that it could be easily missed, and clinicians should recognise that this needs to be considered as part of the overall messaging around sepsis throughout the pathway.

Respondent 15 feedback

No feedback on this question.

Respondent 16 feedback

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Respondent 17 feedback

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Respondent 18 feedback

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Respondent 19 feedback

Evidence appears almost unchanged, and pathway is sensible and pragmatic.
The use of ciprofloxacin as first line and NICE advice on antimicrobial stewardship and C Diff
For the layout, particularly for the algorithm, we appreciate the need to try and put all the information in one page however it makes it very congested and less accessible to follow.
The text is stepwise and helpful but again compared to other resources (namely CKS) it is harder to follow.
To enhance accessibility, we recommend trying to use single colour gradients and accounting for those who have colour differentiation challenges.
Similarly, the text size is small and for those with dyslexia or challenges with text-based information, the flow and content are not succinct.
Overall, the information is clinically sound and follows known principles. We believe it lends itself well for teaching purposes and is likely to be used.
The rationale is correct but one has to read the passage a couple of times to reassure yourself that it is in line with visual pathway that is, don’t send samples for uncomplicated UTI in adult women under 65. This needs to be made clearer.

Response:

Thank you for the feedback.
We don’t recommend ciprofloxacin but agree that reducing its use is important to improve AMS and reduce C. diff.
We have published the algorithm in one page but will also provide users with a Word version that can be modified into two pages if desired.
Thank you. We will look to make the flow as succinct as possible.
The use of a colour traffic light system has been requested and tested by users. We have tested the resource to ensure that the colours and related contrast aligns to current accessibility standards.
The images are now published in web versions so users can enlarge the graphics to increase text size as needed.
Thank you.
The web text currently mirrors the pathway, but we will look to see if we can improve readability by adjusting the lay out.

Respondent 20 feedback

No feedback on this question.

Question 4

Diagnostic points for men under 65 years: web text and rationale

Accepted Answer

Respondent 1 feedback

Respondent 1 details

Good rationale – a flow chart would also be nice.

Response: Thank you. We can consider the development of a decision tool for men in future work.

Respondent 2 feedback

No feedback for this question.

Respondent 3 feedback

Additional diagnostic point in men under 65 section consider re-paraphrasing as confusing to read.

Response: We will look at the wording of this to try and make it clearer.

Respondent 4 feedback

No feedback for this question.

Respondent 5 feedback

No feedback for this question.

Respondent 6 feedback

Respondent 6 details

The intended use for lodestar rapid LAMP technology is for women with uncomplicated UTI’s but it is intended to expand the intended use to cover men following real world evaluations.

Response: At this point of the review, we cannot endorse alternative rapid diagnostic tests for use in UTIs within the UK. However, we will communicate with agencies who have this remit and update the diagnostic guidance once they are recommended for use within the NHS.

Respondent 7 feedback

Respondent 7 details

recurrence or relapsing UTI - definition of recurrent infections to be added?
following statements are contradictory - Do not use dipsticks to rule out infection as they are unreliable for this (see rationale). A urine dipstick test with positive nitrates makes UTI more likely in men (PPV 96%). Negative for both nitrite and leucocyte make UTI less likely, especially if symptoms are mild. (why give information on how to use urine dip to make diagnosis if not recommended?).
signpost to NICE cancer guidance for visible haematuria alone?

Response:

Thank you for your comments. In the web text we will state that, for men, clinicians should refer or seek specialist advice for the further investigation and management of recurrent or relapsing UTI. We have also put in the definition for recurrent UTI.
The authors the work cited in the evidence base concluded that though the positive predictive value was high for dipsticks that showed nitrites (96%) the negative predictive value was low (41%) adding leucocytes to the results didn’t change the results considerably. Because of this the flowcharts say that dipsticks can be useful at ruling in UTI but less useful when ruling out UTI. We will look to clarify this in the wording around this in the text.
We will look to signpost to NICE cancer guidance for haematuria in this section.

Respondent 8 feedback

This seems sensible.

Response: Thank you for the feedback.

Respondent 9 feedback

Useful information.

Response: Thank you for the feedback.

Respondent 10 feedback

Guidance that links to other ‘relevant’ sub-guidance is just wasting time in a consultation, have it all in one place, and commit to keeping it up to date, rather than linking to other organisations guidance that you assume they are keeping the link live and up to date.

Response: We are unable to duplicate guidance from other agencies unless specifically relevant to UTI diagnostics. It is only the information currently presented in the tool that is covered under this consultation.

Respondent 11 feedback

The below is confusing - conflicting advice

Do not use dipsticks to rule out infection as they are unreliable for this (see rationale).
A urine dipstick test with positive nitrates makes UTI more likely in men (PPV 96%). Negative for both nitrite and leucocyte make UTI less likely, especially if symptoms are mild.

Response: The authors cited in the evidence base concluded that though the positive predictive value was high for dipsticks that showed nitrites (96%) the negative predictive value was low (41%) adding leucocytes to the results didn’t change the results considerably. Because of this the flowcharts say that dipsticks can be useful at ruling in UTI but less useful when ruling out UTI. We will look to clarify this in the wording and use the statement Use dipsticks to rule in infection, A urine dipstick test with positive nitrates makes UTI more likely in men (PPV 96%). This will make the impact of the two statements clear.

Respondent 12 feedback

No feedback for this question.

Respondent 13 feedback

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Respondent 14 feedback

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Respondent 15 feedback

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Respondent 16 feedback

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Respondent 17 feedback

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Respondent 18 feedback

Respondent 18 details

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Respondent 19 feedback

Overall, it is easy to follow. We are pleased to see that it emphasises that most urinary symptoms are not UTIs. However, we recommend considering if this is a symptom due to BPH, prostate cancer or bladder cancer if the patient is a smoker. Simple UTIs is rare in adult men.
The section stating: It is important not to use dipsticks to rule out infection as they are unreliable for this (see rationale), is simple and understandable. However, we believe that the next sentence should start with - Use dipsticks to rule in infection, A urine dipstick test with positive nitrates makes UTI more likely in men (PPV 96%). This will make the impact of the two statements clear.
A negative for both nitrite and leucocyte makes UTI less likely, especially if symptoms are mild. We believe this is confusing as this is using a dipstick to rule out infection (contradicts the above statement suggesting not using a dipstick to rule out infection).

Response:

Thank you for your comments. We will look to include and cite this information within this section.
(and 3) The authors the work cited in the evidence base concluded that though the positive predictive value was high for dipsticks that showed nitrites (96%) the negative predictive value was low (41%) adding leucocytes to the results didn’t change the results considerably. Because of this the flowcharts say that dipsticks can be useful at ruling in UTI but less useful when ruling out UTI. We will look to clarify this in the wording and change to: Use dipsticks to rule in infection, A urine dipstick test with positive nitrates makes UTI more likely in men (PPV 96%). Do not use dipsticks to rule out infection as they are unreliable for this (see rationale)

Respondent 20 feedback

No feedback for this question.

Question 5

Diagnostic decision tool for adults over 65 years with suspected uncomplicated UTI: algorithm, web text and rationale

Accepted Answer

Respondent 1 feedback

Respondent 1 details

Useful to highlight ‘‘new delirium/debility’’ alone not an indication for treatment without ruling out other causes - as care home elderly patients often felt to have a UTI when likely only have colonisation
Also not using dipsticks is useful - but will bladder cancers get missed if never dip?

Response:

Thank you for noting this.
This tool provides a reference for management of acute non-recurrent UTI. Urine dipsticks are not recommended for the diagnosis of UTI in groups at higher risk of asymptomatic bacteriuria. However, the tool does not provide guidance on the use of urine dipsticks for other reasons. We have included statements in the text for each group that reminds clinicians to refer people with unexplained or persistent haematuria or suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral in the web text of every section within the tool.

Respondent 2 feedback

No feedback for this question.

Respondent 3 feedback

Same comment as women under 65 (that is, those who have Sepsis and Pyelonephritis sections separately).
Section 4 on flow chart - what is the definition of ‘mild symptom’ and ‘back-up antibiotics’ and ‘more than mild’ symptoms. If discretion of physician, this can be open to interpretation.
‘Back-up antibiotic’ not on prescribing guidelines (just first and second choice). What are ‘back-up’ antibiotics?

Response:

This has been noted, thank you.
The severity of symptoms and their impact on daily life will be unique to patients and needs to be part of the shared decision-making process. It is important that this is open to interpretation as every patient is different.
We will link to NICE (NG109) that discusses the use of back-up antibiotics as a management option for some women with acute UTI including additional guidance needed for patients.

Respondent 4 feedback

No feedback for this question.

Respondent 5 feedback

Urine Dipsticks section - suggest rewording ‘Urine dipsticks are more unreliable with increasing age over 65 years’. It isn’t the test that is more unreliable, it is the user interpretation that is more unreliable, and this applies dipsticks being used in a higher prevalence group for Asymptomatic Bacteriuria.
The age cut-off is difficult to make, and I appreciate you have to draw a line somewhere, but I think it is more complex than just saying over 65yrs. ASB is more prevalent in frailty and with multiple comorbidities, so patients 65yrs = no dipstick’ which comes across in the flowchart.
There is very limited mention of genitourinary syndrome of menopause in the Urine Dipstick section and in the flowchart, when this is extremely common and under-recognised/treated in primary and secondary care. Can the information on GSM be expanded/provided somewhere in this toolkit to include the wider range of symptoms and link to more information on this? Vaginal oestrogen is highly effective at preventing UTI and this document would be a high impact resource to include signposting to information on this.

Response:

Thank you for your comments. We will re-word this text to clarify this
We have a statement saying this in the text that corresponds with this flowchart. In the flowchart, we have added a statement to ask users to refer to the web text and aims and implications section for additional information on the use of the tool, where this issue is highlighted.
This tool focuses on diagnosis of UTI, so we are not able to include additional management advice. We do have information in the linked rational around GSM and have added a link to NICE guideline (NG23) Menopause: diagnosis and management and the NHS menopause overview as resources a user could refer to for further information.

Respondent 6 feedback

Respondent 6 details

No feedback for this question.

Respondent 7 feedback

On the quick reference tool, there is no opening comment about ‘may be more suitable for some younger patients in care homes or with complex co-morbidities.’ The exclusions aren’t listed- look to include this?
https://www.nhs.uk/common-health-questions/infections/how-should-i-collect-and-store-a-urine-sample/ - link no longer valid.
visible haematuria - if only symptom consider further assessment/referral with symptoms (see NICE guideline on suspected cancer for recognition and referral criteria)

Response:

We have added a statement for users to refer to the aims and implications and web text at the top of the tool, where this is explained in further detail.
Thank you for identifying this. NHS have removed the guidance that has been referred to and we are working with NHSE to find another link to include.
We have added a statement to the resource web text to say to refer people with unexplained or persistent haematuria or suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral.

Respondent 8 feedback

This seems sensible.

Response: Thank you for the feedback.

Respondent 9 feedback

Respondent 9 details

The print version does not have suspected uncomplicated UTI in the title of the algorithm.
It might be useful to signpost the diagnostic points for men within this algorithm.
Also, the hyperlink for obtain urine sample does not work as the page has been removed.

Response:

We have added a statement to the top of flowchart to ask users to refer to the aims and implications and corresponding web text for more information on clinical decision making and target groups.
Thank you - we have done this in the web text.
Thank you for identifying this. NHS have removed the guidance that has been referred to and we are working with NHSE to find another link to include.

Respondent 10 feedback

Again, this is too busy with superfluous detail, you are a third of the way in before it’s about UTI in over 65s.

Response: The steering group and reviewers feel it is very important to exclude sepsis and pyelonephritis before users diagnose/manage a lower UTI. Hopefully those familiar with the process can skip to the middle of the page if necessary.

Respondent 11 feedback

Clear and easy to follow - the different colours make it clearer. I like that the sepsis concerns are in a red colour.

Response: Thank you for the feedback.

Respondent 12 feedback

Respondent 12 details

No feedback on this question.

Respondent 13 feedback

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Respondent 14 feedback

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Respondent 15 feedback

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Respondent 16 feedback

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Respondent 17 feedback

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Respondent 18 feedback

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Respondent 19 feedback

We are pleased to see STIs considered in older people.
Temperature above 1.5°C of a person’s normal temperature is unhelpful. We recommend providing a number as no one knows their usual temperature, as this may be an unnecessary complication. Pyrexia is pyrexia in primary care, they are not being monitored in bed.
We believe retention for older men should be in symptoms as it can often aggravate prostatic issues.
We are concerned that age cut-offs seem to vary in the guidance, and we wonder whether your pathways should also consider this approach. Frailty is a better indication of how UTI should be approached than age and adults with frailty are more likely to deteriorate more quickly and this is relevant in terms of risk of delirium.
We would also recommend the use of 4AT in diagnosing delirium.
We are concerned that dysuria is promoted as a single sign. The referenced study concludes that painful voiding is a symptom more associated with UTI in older people but burning pain is not. As both of them are symptoms of dysuria, this appears confusing. We question with the small numbers in the cohort study and this contradiction whether this is sufficient evidence to back up the decision to base the initial diagnosis on dysuria alone.

Response:

Thank you for the feedback
We have changed the wording to show that the sign is fever, and the parameters are an example as this was considered useful when patients are frail and being cared for by others
We have not found evidence to support the inclusion of urinary retention as a symptom of UTI in men. We have highlighted the need to refer to the diagnostic points for men under 65 years to find more information about prostate issues
We have highlighted the issue related to age cut offs in the aims and implications sections and in the web text for this resource. We have included text at the top of the flowchart to ask users to refer to this
We have referenced the 4AT tool and linked users to the NICE CKS website
We have added to the evidence review to strengthen the justification for the inclusion of dysuria as a symptom

Respondent 20 feedback

No feedback on this question.

Question 6

Diagnostic decision tool for adults who have a suspected catheter-associated UTI (CAUTI): algorithm, web text and rationale

Accepted Answer

Respondent 1 feedback

Respondent 1 details

Useful and simple.

Response: Thank you for the feedback.

Respondent 2 feedback

I’m a urologist and am often asked to change a normal, functioning catheter in someone with a UTI. I don’t know of any evidence that changing a functioning catheter in someone with a UTI makes any difference to their infection as that catheter will probably be colonised with bacteria within 24hrs. In fact, if the catheterisation is difficult then changing the catheter ahead of schedule might cause more problems than it solves.

Please review the advice on catheter change unless there is good evidence to the contrary.

Response:

Thank you for the comment. This mirrors the wording in NICE and is based on one RCT in older adults that showed significant improvements in cure rates, mortality, and microbial growth.

Respondent 3 feedback

Same comment as women under 65 – that is, those who have Sepsis and Pyelonephritis sections separately.

Response: This has been noted, thank you.

Respondent 4 feedback

No feedback on this question.

Respondent 5 feedback

No feedback on this question.

Respondent 6 feedback

Respondent 6 details

The intended use for lodestar rapid LAMP technology is for women with uncomplicated UTI’s but it is intended to expand the intended use to cover catheterised patients following real world evaluations.

Response: At this point of the review, we cannot endorse alternative rapid diagnostic tests for use in UTIs within the UK. However, we will communicate with agencies who have this remit and update the diagnostic guidance once they are recommended for use within the NHS.

Respondent 7 feedback

https://www.nhs.uk/common-health-questions/infections/how-should-i-collect-and-store-a-urine-sample/ - link no longer valid.
visible haematuria - if only symptom consider further assessment/referral with symptoms (see NICE guideline on suspected cancer for recognition and referral criteria)

Response:

Thank you - we will look to find another document to link to.
We have added as statement to the resource web text to say to refer people with unexplained or persistent haematuria or suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral.

Respondent 8 feedback

Respondent 8 details

Adults over 65 and CAUTI are in the same algorithm. I don’t really like this as they are different problems, although agree they have similar diagnostic issues.
I don’t know the data on this, but I suspect age is not the main problem - it is comorbidity and the difficulty in getting a proper history and specimen. Dipstick negative urine can be helpful in the elderly, and I wonder if it is helpful as a rule out in patients over 65 who can provide good specimens. But agree this is a complex message to get across. I think a lot of the data on poor dipstick PPV is on hospitalised patients.
One of the boxes says ‘‘UTI likely’’ and I don’t really like this. I would say ‘‘UTI possible’’. We don’t have a good way of describing this uncertainty, but I think we should resist giving people an easy diagnosis that is probably wrong.
Diagnosis is almost impossible. I think the guidance says give antibiotics if bypassing or blocked. Is there evidence for this? I would say hydrate and consider catheter valve. Definitely wouldn’t give antibiotics.

Response:

We have separated out the algorithms in the updated so hopefully this will help clarify things
We did a rapid review of the usefulness of using dipstick to rule out infection in older adults and found there was very little evidence to support. We are currently working with University Oxford to conduct a systematic review of the evidence base around risk factors for ASB, including age/frailty and are hoping this will further inform recommendations. We have tried to word the recommendations in this area in a way that indicates the inconsistencies in the current evidence base.
We discussed this with the steering group and concluded that most people who work within primary care understand what is meant by ‘UTI likely’ and ‘UTI less likely’ etc. We feel that adding additional information will take away from the usability of the guidance.
UTIs can cause catheters to become blocked. We will remove this statement as these patients will be captured in other parts of the flowchart.

Respondent 9 feedback

The information is useful, but it would be helpful to include the following:

No TARGET UTI leaflet for the patient on how to care for their catheter.
The sample from the catheter information should be included, that is, from the catheter port using an aseptic non-touch technique.

Response:

Thank you for the comments. We will include this as a request for the TARGET team. The current adult UTI leaflet covers those who have a catheter in place.
This has been noted and will be added to the text.

Respondent 10 feedback

Again, too busy and wordy with unnecessary detail.

Response: We have tried to make the flowcharts as simple to follow as possible.

Respondent 11 feedback

Clear and easy to follow, good guidance on not performing urinalysis.

Response: Thank you for the feedback.

Respondent 12 feedback

No feedback on this question.

Respondent 13 feedback

Respondent 13 details

CAUTI catheter UTI flowchart: at the bottom of number 1, it should say “rule out other causes - see box 6” (rather than “rule out other causes- *see box below”), so delete the crucifix before rule as well as there’s no crucifix at the bottom to take you to.

Box 6 doesn’t really need the “symptoms or signs of” as that’s obvious, and “check all for other localised infection” implies this.

Neater to put “follow local diagnostic and treatment guidance” in the same box rather than arrow to another box. Same with the box “advise watchful waiting….” below box 6. The arrow to the pink box 8 could be from box 6.

Response: Thank you for the feedback. We have changed the text in these boxes to follow a path similar to what you outline here.

Respondent 14 feedback

No feedback on this question.

Respondent 15 feedback

Respondent 15 details

Just one comment here. The pathway doesn’t mention taking a mid-stream specimen if the catheter has been removed, it just states remove if possible, and obtain a specimen from new catheter but if just removed there is no mention unlike the NICE guideline (NG113).

Response: Thank you for the feedback. This has been noted and we will incorporate this into the explanatory web text.

Respondent 16 feedback

No feedback on this question.

Respondent 17 feedback

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Respondent 18 feedback

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Respondent 19 feedback

Respondent 19 details

We agree with the pathway but recommend providing stronger emphasis on the fact that fever + delirium + positive MSU does not necessarily = UTI as the cause. This may help to reduce the number of hospital discharge letters that attribute these symptoms to UTI, when other relevant conditions are not investigated.
As with the elderly, it is important to distinguish that, with lower and upper UTIs, Nitrofurantoin is sometimes used inappropriately because of diagnostic confusion, and lower UTIs are over diagnosed in catheterized patients (and sometimes upper UTI underdiagnosed).
For paragraph 3, we would like to make the same comment as above regarding the temp of 1.5°C above normal, twice in the last 12 hours. This is not a practical situation for general practice and would suggest rewording it.
We recommend including something about the person or carer checking catheter outflow after the initial assessment.

Response:

Thank you for the comments. We can move this statement to the top of the list of bullet points and look to make it more prominent within the design.
This has been noted. We differentiate the symptoms of pyelonephritis and CAUTI in the flowchart so hopefully this will help ensure more accurate diagnosis.
We have changed the wording to show that the sign is fever, and the parameters are an example as this was considered useful when patients are frail and being cared for by others.
This has been noted and we have included the statement to remind users that UTIs can cause urinary catheters to bypass or become blocked.

Respondent 20 feedback

No feedback on this question.

Question 7

Rationale for sending urine for culture and interpreting results in all adults: web text and rationale

Accepted Answer

Respondent 1 feedback

Respondent 1 details

Simple and useful.

Response: Thank you for the feedback.

Respondent 2 feedback

No feedback on this question.

Respondent 3 feedback

Section: Urine Sampling in Different Group - People with Urinary Catheters - consider rewording as staff are always taught to follow ANTT for catheter insertion and sampling.

Response: We will move “using ANTT” to just after the urine sample and change aseptic technique to ANTT.

Respondent 4 feedback

No feedback on this question.

Respondent 5 feedback

The risk factors of when to send culture: I would favour ‘Antibiotic Allergy/ies’ being added to this list, as these patients are both at increased risk of resistance and are likely to receive 2nd or 3rd line therapies. This will enable laboratories to provide a greater range of antibiotic susceptibility tests to ensure effective treatment choices are available (similar rationale to including renal impairment where antibiotic options are more limited).
Epithelial cells and mixed growth section: would suggest that the wording is reviewed re: mixed growth, for example, ‘Mixed growth may indicate perineal contamination, delay in sample transport/processing, or genuine mixed infection. Genuine mixed UTI is more common in older patients. If symptomatic consider re-test and discussion with microbiologist regarding possibility of mixed infection and further culture results’.
The box acknowledges that most labs in the UK do not culture down to the evidence-based standards for UTI of 10² or 10³ cfu/ml. However, I think this needs more explicit explanation that a culture result of no significant growth or no growth at standard thresholds in women with symptoms and pyuria, should prompt discussion with a microbiologist to provide lower colony counts. The demand needs to be created for labs to start providing what is clinically required. This is an area that the UKHSA SMI does not follow the evidence, and this document does should feed into the UKHSA working party on SMIs to drive change, rather than just accepting the status quo as there is a clear mismatch here between the evidence cited and stated in this box, and what users get in reality from UK laboratories.

Response:

Thank you for the comments. We discussed this with the steering group and agreed not to include it. Allergy information should be sent with the sample itself if one is needed, however an allergy itself is not a reason to send a sample. There are lots of options for UTI management from different classes of antibiotics.
We have re-worded this section.
We have added in a statement to say that not all labs may be able to provide lower colony counts, so a consultation with microbiology may be needed.

Respondent 6 feedback

Respondent 6 details

The utilisation of culture and sensitivity testing is well established and will continue, however the ability to detect the following pathogens* via rapid LAMP (molecular) technology such as The Lodestar will enable a more rapid decision in prescribing antibiotics with greater clinical effects.

E. coli, Enterococcus spp, Staphylococcus saprophyticus, Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella spp: preliminary clinical results show overall sensitivity of 91% and specificity of 88%.

Response: This review cannot endorse alternative rapid diagnostic tests for use in UTIs within the UK. However, we will communicate with agencies who have this remit and update the diagnostic guidance once they are recommended for use within the NHS.

Respondent 7 feedback

Send urine sample for culture: ‘visible or non-visible (dipstick) haematuria’ - should be included in line with CKS guidance.

Response: Because this tool is for women with non-recurrent primary UTI, haematuria would be explained as a symptom of UTI. NICE provide guidance on cancer management and referral, and we have included statements in the text for each group that reminds clinicians to refer people with unexplained or persistent haematuria or suspected cancer in line with the NICE guideline on suspected cancer: recognition and referral in the web text of every section within the tool.

Respondent 8 feedback

Respondent 8 details

See previous feedback for CAUTI. We have such poor evidence on which to base guidance on this important problem.

Response: This has been noted, thank you.

Respondent 9 feedback

Useful information.

Labs use culture cut-offs to support the diagnosis of UTI rather than indicate the presence of UTI.

Response: Thank you for the feedback.

This has been noted and the text will be updated.

Respondent 10 feedback

Why is this separate from the diagnostic guidance pathways? It should be integral.

Response: This content has always been separated from the flowcharts as it allows users to refer if they would like more detailed information.

Respondent 11 feedback

Clear list of patient groups to send MSUs on.

Response: Thank you for the feedback.

Respondent 12 feedback

No feedback on this question.

Respondent 13 feedback

Respondent 13 details

No feedback on this question.

Respondent 14 feedback

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Respondent 15 feedback

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Respondent 16 feedback

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Respondent 17 feedback

Respondent 17 details

No feedback on this question.

Respondent 18 feedback

No feedback on this question.

Respondent 19 feedback