Rosalie Allison and Professor Cliodna McNulty discuss the new PHE recommendations on UTIs and how the guidance supports responsible antimicrobial prescribing

Rosalie Allison

Rosalie Allison

Cliodna McNulty

Professor Cliodna McNulty

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Read this article to learn more about:

  • the new PHE diagnostic flowcharts for urinary tract infection (UTI) and how they can improve patient outcomes and antimicrobial stewardship
  • why dipstick tests are no longer recommended in older people with suspected UTI
  • when to send urine for culture, and when to prescribe an antibiotic.

Symptoms associated with urinary tract infections (UTIs) are one of the most common, acute reasons for women to seek health care. UTIs cause significant pain and interfere with daily routine. The results of a 2014 UK-based survey revealed that:1

  • in the previous year, 11% of women reported a UTI and 3% reported recurrent UTI
  • of all women who had ever had a UTI, 95% reported consulting a healthcare professional (HCP) and of these, 76% had a urine culture test
  • of all women who contacted an HCP about their last UTI, 74% were prescribed an antibiotic
  • 48% of women rated their last UTI as fairly or very severe.

Optimising the diagnosis of UTIs is important as studies indicate that, of all women in the UK with a suspected UTI who are prescribed an antibiotic and have urine sent for culture, only 24–66% have a confirmed UTI.2,3

Urinary tract infections are most often caused by Escherichia coli (E. coli), which can lead to E. coli bacteraemia (E. coli in the blood) and sepsis.4 Antimicrobial resistance is associated with prolonged symptoms and reconsultation; resistance to trimethoprim has increased so much over the last 10 years that NICE and Public Health England (PHE) only recommend trimethoprim first line if there is known susceptibility or a low risk of resistance.5,6 Increasing resistance, and an increasing prevalence of older people with frailty, may explain the rising morbidity associated with UTIs. Between 2013–2017, the reported number of cases of E. coli bacteraemia increased by 35%, from 12,250 to 16,504.7 The highest rates of E. coli bacteraemia infections in England are observed among older people, with key risk factors including: catheterisation, recurrent UTI, or antibiotic use in the previous 28 days.8,9

Development of a UTI tool for primary care

In November 2018, PHE published Diagnosis of urinary tract infections: quick reference tool for primary care,10 which replaces previous PHE guidance on UTIs. The tool contains new diagnostic flowcharts and recommendations based on the latest available evidence, and has been endorsed by NICE. The guidance was developed following an extensive needs assessment and discussions on how suspected UTIs are managed in GP practices, out-of-hours services, and care homes.

When is treatment with antimicrobials appropriate?

Urinary tract infections are among the most common infections in primary care, but predicting the probability of UTIs using symptoms and point-of-care tests can be inaccurate, leading to inappropriate antimicrobial use. The aim of the quick reference tool is to improve the management of UTIs in the community by: providing an effective, economical, and empirical approach to diagnosis; clarifying when it is appropriate to prescribe an antimicrobial; and minimising the emergence of antibiotic resistance in the community.

The new diagnostic flowcharts and diagnostic points include:

  • women aged under 65 years (see Figure 1)
  • men aged under 65 years (see Box 1)
  • older people aged over 65 years (see Figure 2)
  • infants and children aged under 16 years with suspected UTI (see Figure 3).

Key changes from previous PHE guidance include:

  • for women aged under 65 years, use three specific indicators (dysuria, new nocturia, cloudy urine) to increase diagnostic certainty of a UTI rather than any of the three symptoms
  • for men and women aged over 65 years:
    • do not perform a urine dipstick test
    • use PINCH ME (see Figure 2) to exclude other causes of delirium
  • always exclude vaginal and urethral causes of urinary symptoms, including urethritis and genitourinary syndrome of menopause.

PHE UTI in women under 65

Figure 1: Flowchart for women aged under 65 years with suspected UTI10

UTI=urinary tract infection; NICE=National Institute for Health and Care Excellence; RCGP=Royal College of General Practitioners; NEWS2=National Early Warning Score 2; PHE=Public Health England; RBC=Red blood cells; TARGET=Treat Antibiotics Responsibly, Guidance, Education, Tools

Source: Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Reproduced under the Open Government Licence for public sector information

Box 1: Diagnostic points for men aged under 65 years10

Diagnostic points for men under 65 years

  • Asymptomatic bacteriuria is rare in men <65 years

Consider other genitourinary causes of urinary symptoms

  • In sexually active, check sexual history for STIs for example chlamydia and gonorrhoea
  • Urethritis due to urethral inflammation post sexual intercourse, irritants, or STIs

Check for pyelonephritis, prostatitis, systemic infection, or suspected sepsis using local policy

  • Urinary symptoms with fever or systemic symptoms in men are strongly suggestive of prostatic involvement or pyelonephritis
  • Acute prostatitis may present with feverish illness of sudden onset, symptoms of prostatitis (low back, suprapubic, perineal, or sometimes rectal pain), symptoms of UTI (dysuria, frequency, urgency or retention), or exquisitely tender prostate on rectal examination
  • Recurrent or relapsing UTI in men should prompt referral to urology for investigation

Diagnostic points in men

  • Always send a mid-stream urine sample for culture, collected before antibiotics are given
  • Dipsticks are poor at ruling out infection. Positive nitrite makes UTI more likely (positive predictive value 96%). Negative for both nitrite and leucocyte makes UTI less likely, especially if symptoms are mild
  • If suspected UTI, offer immediate treatment according to NICE/PHE guideline on Lower UTI: antimicrobial prescribing and review choice of antibiotic with pre-treatment culture results

STI=sexually transmitted infection; UTI=urinary tract infection; NICE=National Institute for Health and Care Excellence; PHE=Public Health England

Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Reproduced under the Open Government Licence for public sector information

PHE UTI in over 65s

Figure 2: Flowchart for men and women aged over 65 years with suspected UTI10

UTI=urinary tract infection; RCGP=Royal College of General Practitioners; NEWS2=National Early Warning Score 2; PHE=Public Health England; RBC=Red blood cells; TARGET=Treat Antibiotics Responsibly, Guidance, Education, Tools; MSU=mid-stream urine; NICE=National Institute for Health and Care Excellence

Source: Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Reproduced under the Open Government Licence for public sector information

PHE UTI in children

Figure 3: Flowchart for infants/children under 16 years with suspected UTI10

UTI=urinary tract infection; NICE=National Institute for Health and Care Excellence; PHE=Public Health England; CG=Clinical Guideline

Source: Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Reproduced under the Open Government Licence for public sector information

Asymptomatic bacteriuria and dipstick tests

Diagnosing suspected UTIs in older people is made more complex by an increasing prevalence of dementia and asymptomatic bacteriuria. Up to half of all older people, and most with a urinary catheter, will have bacteria present in the bladder/urine without an infection. Although this ‘asymptomatic bacteriuria’ will test positive on a urine dipstick and is associated with pyuria, it is not harmful and therefore antibiotics are not beneficial and may only contribute to increasing antibiotic resistance.11–14 For this reason, dipstick tests are no longer recommended by PHE in people aged over 65 years.

Treatment options and resistance

Increasing resistance to narrow spectrum antibiotics limits the available treatment options in all ages. There remains a difficult balance between the clinical, empirical management of UTIs using broad-spectrum antibiotics in all age ranges, and the development of antibiotic resistance in the community.12 Table 1 shows the level of resistance of E. coli to antibiotics used to treat UTI in 2018. Trimethoprim resistance in England is now at 28.6% of E. coli urine isolates, compared with only 2% for nitrofurantoin, and 6% for pivmecillinam.15 Nitrofurantoin is therefore a first-line antibiotic to consider in all patients (except women who are pregnant at term). Nitrofurantoin attains low urinary concentrations in patients with poor renal function, so other antibiotics should be considered if estimated glomerular filtration rate (eGFR) is <45 ml/min, including trimethoprim (if risk of resistance is low), pivmecillinam, or fosfomycin. 

NICE and PHE now recommend cefalexin as a first-line treatment for oral treatment of pyelonephritis in the community as resistance to this antibiotic is now lower than resistance to co-amoxiclav and randomised controlled trials show that it is equally effective.16,17

Table 1. Escherichia coli (E. coli) resistant to different antimicrobials in 2018-Quarter 3 (urine specimens only)15
 Antimicrobial tested against

Public Health England. Field Epidemiology Field Service NIS. Antibiotic drug-bug resistance profile workbooks (Community edition). PHE 2018.

Reproduced under the Open Government Licence for public sector information

  Nitrofurantoin Pivmecillinam Cefalexin Ciprofloxacin[1] Co-amoxiclav Trimethoprim
No. tested against given antimicrobial 118,913 66,080 99,165 95,271 109,503 127,790
No. resistant to given antimicrobial 2,459 3,990 9,213 9,760 23,970 36,536
% resistant to given antimicrobial 2.10% 6.00% 9.30% 10.20% 21.90% 28.60%

Sending urine for culture and interpreting results

Clinicians should be aware of the various indications for sending a patient’s urine for culture, including urinary symptoms in pregnancy, suspected pyelonephritis or sepsis, and suspected UTI in men. Clinicians should also consider risk factors for antimicrobial resistance, and should send urine for culture if the patient is a care home resident, has had a recent hospitalisation (more than 7 days in last 6 months), or has travelled to a country with increased resistance (outside Northern Europe, Australasia and Canada—especially countries in South East Asia). Some CCGs with high resistance in the community are recommending urine culture in all symptomatic patients. The results of the urine culture will help inform the choice of antibiotic. If an antibiotic has already been prescribed, this should be reviewed to see if it is still an appropriate choice. Refer to Box 2 for the full list of indications for sending urine for culture, and how to interpret urine culture results if a UTI is suspected.10

Box 2:  Sending urine for culture and interpreting results in all adults10

Review need for culture when considering treatment

  • Send a urine for culture in:
    • over 65 year olds if symptomatic and antibiotic given
    • pregnancy: for routine antenatal tests, or if symptomatic
    • suspected pyelonephritis or sepsis
    • suspected UTI in men
    • failed antibiotic treatment or persistent symptoms
    • recurrent UTI (2 episodes in 6 months or 3 in 12 months)
    • if prescribing antibiotic in someone with a urinary catheter
    • as advised by local microbiologist
  • Consider risk factors for resistance and send urine for culture if:
    • abnormalities of genitourinary tract
    • renal impairment
    • care home resident
    • hospitalisation for >7 days in last 6 months
    • recent travel to a country with increased resistance
    • previous UTI resistant
  • If prescribing an antibiotic, review choice when culture and antibiotic susceptibility results are available

Sampling in all men and women

  • Women: mid-stream urine (NHS choices) and holding the labia apart may help reduce contamination but if not possible, sample can still be sent for culture
  • Do not cleanse with antiseptic, as bacteria may be inhibited
  • Elderly/frail: only take urine sample if symptomatic and able to collect good sample. If incontinent, clean catch in disinfected container and condom catheters for men may be viable options but little evidence to support
  • Men: advise on how to take a mid-stream specimen (NHS choices)
  • People with urinary catheters: if changed, collect from newly placed catheter using aseptic technique, drain a few mL of residual urine from the tubing, then collect a fresh sample from catheter sampling port
  • Culture urine within 4 hours of collection, refrigerate, or use boric acid preservative. Boric acid can cause false negative culture if urine not filled to correct mark on specimen bottle and can affect urine dipstick tests)

How do I interpret a urine culture result if I suspect a UTI?

  • Culture should be interpreted in parallel to severity of signs/symptoms. False negatives/positives can occur
  • Do not treat asymptomatic bacteriuria unless pregnant as it does not reduce mortality or morbidity
  • Urine culture results in patients with urinary symptoms that usually indicate UTI:
    • many labs use growth of 107–108 cfu/l (104–105 cfu/ml) to indicate UTI
    • lower counts can also indicate UTI if patient symptomatic:
      • strongly symptomatic women—single isolate >105 cfu/l (>102 cfu/ml) in voided urine
      • in men counts as low as 106 cfu/l (103 cfu/ml) of a pure or predominant organism
      • any single organism >107 cfu/l (>104 cfu/ml)
      • Escherichia coli or Staphylococcus saprophyticus >106 cfu/l (>103 cfu/ml)
      • >108 cfu/l (>105 cfu/ml) mixed growth with 1 predominant organism
  • Epithelial cells/mixed growth:
    • the presence of epithelial cells is not necessarily an indicator of perineal contamination, culture result should be interpreted with symptoms and repeated if significance is uncertain
    • mixed growth may indicate perineal contamination; however a small proportion of UTIs may be due to genuine mixed infection. Consider a re-test if symptomatic
  • Red cells:
    • may be present in UTI
    • chemical tests may be more sensitive than microscopy as a result of the detection of haemoglobin released by haemolysis
    • refer patients with persistent haematuria post-UTI to urology
  • White blood cells/leukocytes:
    • white cells >107 WBC/l (>104 WBC/ml) are considered to represent inflammation in urinary tract, this includes the urethra
    • white cells can be present in older people with asymptomatic bacteriuria, as the immune system does not differentiate colonisation from infection
  • Sterile pyuria
    • in sterile pyuria, consider Chlamydia trachomatis (especially if 16–24 years), other vaginal infections, other nonculturable organisms including tuberculosis or renal pathology
    • if recurrent pyuria with UTI symptoms, discuss with local microbiologist as lower counts down to 105 cfu/l (102 cfu/ml) may be significant. Higher volume of urine may need to be cultured, including for fastidious organisms
  • For all patients:
    • take into account of antibiotic susceptibility results and resistance when deciding on management and reviewing antibiotic treatment
  • Follow up:
    • do not send follow-up urine unless pregnant, or advised by the laboratory
    • Consider non-urgent referral for bladder cancer in patients >60 years with recurrent/persistent unexplained UTIs

UTI=urinary tract infection; WBC=white blood cell

Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis

Reproduced under the Open Government Licence for public sector information

Follow-up tests

Follow-up urine culture tests are unnecessary, unless the patient is pregnant, reconsults, or follow up is advised by the laboratory. If a patient aged over 65 years has recurrent, unexplained symptoms, they should be referred to exclude bladder cancer.10

Barriers to implementation

The main challenge that primary care clinicians will face is implementing the changes in recommendations from previous PHE guidance. Specifically, it is now important to assess women aged under 65 years using the three key diagnostic signs/symptoms: dysuria, new nocturia, and cloudy urine. This is more specific than previous recommendations, where patients with any of the three symptoms would be offered empirical antibiotics. In people aged over 65, dipstick tests are no longer recommended, and clinical decisions should be based only on the signs and symptoms outlined in Figure 2. Clinicians are being asked to assess for the signs and symptoms of sepsis and pyelonephritis in all patient groups, which may not have been routinely considered before. The changes in recommendations will probably require local telephone triage systems to be updated accordingly, and more patients may need to collect a urine specimen.

Useful sources of patient information

Public Health England has produced several TARGET treating your infection (TYI) leaflets, which will help practitioners share this new guidance with patients during consultation.18 They aim to facilitate communication between the prescriber and the patient, and increase the patient’s confidence in self-care. The TYI leaflets include information on common symptoms of UTIs, illness duration, and advice on self-care, prevention, and when to reconsult. 

Leaflet for women aged under 65 years

For women under 65 years with suspected lower UTIs or recurrent lower UTIs (cystitis or urethritis). The leaflet has been translated into 19 languages to facilitate practitioner–patient communication. 

Leaflet for older people aged over 65 years

For older people who are at risk of UTI, are experiencing urinary symptoms, or who have been diagnosed with UTI.

Other antimicrobial stewardship tools can be downloaded from the TARGET section of on the RCGP website: www.rcgp.org.uk/TARGETantibiotics.

Summary

The updated PHE UTI guidance10 aims to improve the diagnosis, management, and prevention of suspected UTIs, pyelonephritis, and sepsis in all age groups. Diagnostic algorithms and triage systems in general practice, care homes, and out-of-hours services will need to be updated to include the three key diagnostic symptoms (dysuria, new nocturia, and cloudy urine) for women aged under 65 years, and to not recommend urine dipstick testing in people aged over 65 years. Reducing the use of urine dipsticks in older patients will decrease unnecessary use of antibiotics, and will help to minimise the development of resistance. The new NICE/PHE UTI antibiotic guidance and summaries stress that trimethoprim should only be used in those with low risk of resistance. The guidance encourages the use of nitrofurantoin first line (for people with eGFR ≥45 ml/min). Pivmecillinam may be used for lower UTI in patients with an eGFR <45 ml/min.

Rosalie Allison

Primary Care Unit, Public Health England

Professor Cliodna McNulty

Primary Care Unit, Public Health England

Key points

  • Urinary tract infections affect 11% of women each year. Predicting the probability of UTIs using symptoms and point-of-care tests needs to be improved
  • To improve the management of UTIs and minimise the emergence of antibiotic resistance in the community, PHE has produced the Diagnosis of urinary tract infections: quick reference tool for primary care which covers:
    • people aged under 65 years
    • older people aged over 65 years
    • infants/children aged under 16 years with suspected UTI
  • Following the update, the guideline now recommends:
    • excluding pyelonephritis, sepsis, prostatitis (in men), and any other genitourinary causes of urinary symptoms
    • assessing for the three key diagnostic signs/symptoms in women aged under 65 years: dysuria, new nocturia, and cloudy urine to predict the likelihood of a UTI
    • not performing dipstick tests in older people to diagnose a UTI—many older people will have ‘asymptomatic bacteriuria’, which will test positive but is not harmful
    • using PINCH ME to exclude other causes of delirium in people aged over 65 years
    • considering post-menopausal syndrome as a cause of urinary symptoms in older women
    • sending urine for culture in all patients prescribed an antibiotic for a suspected UTI if there is an increased risk of resistance, recurrent UTI, or relapse (see Box 2 for full indications) and in all people aged over 65 years
    • sharing the TARGET leaflets17 with all patients with suspected UTI
    • using new NICE/PHE antibiotic guidance, which advises nitrofurantoin for lower UTI (if eGFR ≥45 ml/min), trimethoprim if low risk of resistance, or pivmecillinam if eGFR ≤45 ml/min and cefalexin for suspected pyelonephritis.5

UTI=urinary tract infections; PHE=Public Health England; TARGET=Treat Antibiotics Responsibly, Guidance, Education, Tools; eGFR=estimated glomerular filtration rate

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Identify the professional groups for whom this updated guidance is relevant, as it challenges many current practices (e.g. using dipsticks to check urine in people aged over 65); these groups will include pharmacists, out-of-hours providers, and care home staff as well as GPs and nurses
  • Design and implement a communication strategy to ensure all key health and care workers are aware of, and can easily reference, this guidance and the useful flowcharts
  • Consider extending this communication plan to the public to help them to know when to present to healthcare services, and what to expect when they do
  • Provide links to this guidance through local electronic formularies and clinical decision aids or prompts in electronic consulting systems
  • Ensure local formularies reflect the latest guidance on treatment from PHE and NICE.

STP=sustainability and transformation partnership; ICS=integrated care system; PHE=Public Health England; NICE=National Institute for Health and Care Excellence

Implementation actions for clinical pharmacists in general practice

written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.

Agree the scope of patients to be seen within your competence in the management of UTIs for women and/or men under 65 years, older people over 65 years, infants and children, and know how to recognise red flags, i.e. signs of sepsis, pyelonephritis, prostatitis and any other genitourinary causes of urinary symptoms. Practice pharmacists are well placed, with the correct guidance and support, to assess patients with UTIs and prescribe the appropriate antibiotics (if the pharmacist is a prescriber), or recommend the correct antibiotic to a GP/nurse (if the pharmacist is a non-prescriber)

Gain buy-in from:

  • GPs, or practice managers, or mentor—to agree on your role, on GP supervision/mentorship, and on how you can help to educate other clinicians in the practice to understand and adhere to guidelines in line with good practice and antimicrobial stewardship
  • reception and administration staff—to help to triage the correct patients into your clinics
  • patients—to gain their trust and confidence in your clinical judgment and advice

Familiarise yourself with the new PHE guidance, local guidelines, formularies, and referral pathways to ensure adherence to antimicrobial stewardship, use of the correct antibiotics, and subsequent reduction of antimicrobial resistance as well as cost-effective practice. Know how to use PINCH ME (see article) to exclude other causes of delirium in people aged over 65 years, and understand post-menopausal syndrome

Use your knowledge to deliver professional results. Know the three key diagnostic signs/symptoms of UTIs and ensure your knowledge of these is applied in the appropriate patients. Know which patients require a urine dipstick test and ensure that you have an adequate supply of equipment in your clinic room. Know when and how to send off urine samples for culture and how to counsel patients on sampling. Learn how to interpret the urine culture results in line with the guidelines to ensure that the correct treatment is initiated. Use and print the RCGP TYI-UTI patient leaflets to help counsel patients and to increase their understanding

Be alert for opportunistic management. If you are not conducting minor illness clinics in your practice, some patients you see for other long-term conditions/medicine reviews may also complain of urinary symptoms, giving you an opportunity to manage UTIs if the history supports a diagnosis, and to give appropriate counselling and advice

Evaluate your contribution to outcomes. Use and familiarise yourself with the RCGP TARGET audit toolkits and resources to evaluate how your practice is performing with regard to antimicrobial stewardship, and use this as a comparison over time to showcase your contribution to improvements in this area.

UTI=urinary tract infection; PHE=Public Health England; RCGP=Royal College of General Practitioners; TYI-UTI=treating your infection—urinary tract infection; TARGET=Treat Antibiotics Responsibly, Guidance, Education, Tools

References

  1. Butler C, Hawking M, Quigley A, McNulty C. Incidence, severity, help seeking, and management of uncomplicated urinary tract infection: a population-based survey. Br J Gen Pract 2015; 65 (639): e702–707.
  2. Little P, Moore M, Turner S et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ 2010; 340: c199.
  3. Butler C, Francis N, Thomas-Jones E et al. Variations in presentation, management, and patient outcomes of urinary tract infection: a prospective four-country primary care observational cohort study. Br J Gen Pract. 2017; 67 (665): e830–e841.
  4. Abernethy J, Johnson A, Guy R et al. Thirty day all-cause mortality in patients withEscherichia coli bacteraemia in England. Clin Microbiol Infect 2015; 21 (3): 251 e1–e8.
  5. McNulty C, Richards J, Livermore D et al. Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother 2006; 58 (5): 1000–1008.
  6. NICE. Summary of antimicrobial prescribing guidance—managing common infections. NICE and PHE, 2018. Available at: www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/antimicrobial-prescribing-guidelines
  7. Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). PHE, 2018. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/759975/ESPAUR_2018_report.pdf
  8. Public Health England. HPR volume 10 issue 19: news (17 June). www.gov.uk/government/publications/health-protection-report-volume-10-2016/hpr-volume-10-issue-19-news-17-june (accessed 17 January 2019).
  9. Abernethy J, Guy R, Sheridan E et al. Epidemiology of Escherichia coli bacteraemia in England: results of an enhanced sentinel surveillance programme. J Hosp Infect 2016; 5 (4): 365–375.
  10. Public Health England. Diagnosis of urinary tract infections. Quick reference tool for primary care: for consultation and local adaptation. PHE, 2018. Available at: www.gov.uk/government/publications/urinary-tract-infection-diagnosis.
  11. Nicolle L, Mayhew W, Bryan L. Prospective randomized comparison of therapy and no therapy for asymptomatic bacteriuria in institutionalized elderly women. Am J Med 1987; 83 (1): 27–33.
  12. Augustine S, Bonomo R. Taking stock of infections and antibiotic resistance in the elderly and long-term care facilities: a survey of existing and upcoming challenges. Eur J Microbiol Immunol (Bp) 2011; 1 (3): 190–197.
  13. Costelloe C, Metcalfe C, Lovering A et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010; 340: c2096.
  14. Ahmed H, Farewell D, Jones H et al. Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004–2014. PLoS One 2018; 13 (1): e0190521.
  15. Public Health England. Field Epidemiology Field Service NIS. Antibiotic drug-bug resistance profile workbooks (Community edition). PHE 2018.
  16. NICE. Pyelonephritis (acute): antimicrobial prescribing. NICE Guideline 111. NICE, 2018. Available at: www.nice.org.uk/guidance/ng111
  17. NICE. Pyelonephritis (acute): antimicrobial prescribing. Evidence review. NICE Guideline 111. NICE, 2018. Available at: www.nice.org.uk/guidance/ng111/evidence/evidence-review-pdf-6545799181
  18. RCGP. TARGET Antibiotics Toolkit. PHE. www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotics-toolkit.aspx. (accessed 17 January 2019).