Quality standard

Quality statement 1: Diagnosing urinary tract infections in women under 65

Quality statement 1: Diagnosing urinary tract infections in women under 65

Quality statement

Women aged under 65 years are diagnosed with a urinary tract infection (UTI) if they have 2 or more key urinary symptoms and no other excluding causes or warning signs. [new 2023]

Rationale

Diagnosing UTI correctly supports appropriate management and reduces unnecessary antibiotic prescribing and the risk of antimicrobial resistance. No single symptom or combination of symptoms is completely reliable in diagnosing UTI. Before diagnosing a UTI, vaginal and urethral causes of urinary symptoms need to be excluded. This is because the presence of vaginal discharge or vaginal irritation substantially reduces the probability of a UTI, and vaginal infections and some sexually transmitted diseases can mimic the symptoms of a UTI. Diagnosis of a UTI in women under 65 can be made with an increased likelihood when 2 or more key urinary symptoms are present. Key symptoms can also be used to guide treatment. Signs and symptoms of sepsis, pyelonephritis and cancer should also be considered during diagnosis so that any appropriate action can be taken.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Process

a) Proportion of episodes of suspected UTI in women aged under 65 with signs and symptoms documented in the patient's records.

Numerator – the number in the denominator with signs and symptoms documented in the patient's records.

Denominator – the number of episodes of suspected UTI in women aged under 65.

Data source: Data can be collected from information recorded locally by provider organisations, for example from GP practice computer systems. Data collection forms are available to collect information on UTI symptoms from GP patients. Some forms collect data using text messages and mobile phones, and allow the data to be saved to the patient's electronic record. NHS England's Pharmacy Quality Scheme Guidance 2022/23 includes a data collection form for community pharmacy teams which collects information on UTI symptoms at consultations for women aged under 65.

b) Proportion of women aged under 65 years diagnosed with a UTI who have 2 or more key urinary symptoms and no other excluding causes or warning signs.

Numerator – the number in the denominator who have 2 or more key urinary symptoms and no other excluding causes or warning signs.

Denominator – the number of women aged under 65 diagnosed with a UTI.

Data source: No routinely collected data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

Prescription rates for antibiotics used for lower UTIs (such as trimethoprim, nitrofurantoin, fosfomycin or pivmecillinam).

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from prescribing systems. Note that the antibiotics listed in the measure will not capture all UTI prescribing. The listed antibiotics are either exclusively or predominately used for UTI and so are unlikely to have been prescribed for something else. OpenPrescribing.net includes a measure (KTT9) which shows the volume of all antibiotic prescribing per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU). The number of prescribed items for different antibiotics contributing to the total rate is also listed.

What the quality statement means for different audiences

Service providers (such as GP practices, hospitals, walk-in centres, urgent treatment centres, pharmacies) ensure that procedures are in place to assess and document the signs and symptoms of women aged under 65 presenting with a suspected UTI. Providers ensure that information on the key urinary symptoms and how to exclude other causes and warning signs is available to healthcare professionals.

Healthcare professionals (such as GPs, physician associates, nurses, hospital doctors and community pharmacists) assess the signs and symptoms of women aged under 65 presenting with a suspected UTI. They ensure that vaginal and urethral causes of urinary symptoms are excluded by asking about vaginal discharge and irritation, and other possible urethral causes of urinary symptoms. They use the presence of 2 or more key urinary symptoms to diagnose a likely UTI and guide treatment. They also check for signs and symptoms of sepsis, pyelonephritis and cancer in case urgent action is needed to address these.

Integrated care systems lead on antimicrobial stewardship in their area.

Women aged under 65 with symptoms of a UTI are given a diagnosis of a UTI if they have 2 or more key urinary symptoms and other possible causes of the symptoms have been ruled out.

Source guidance

Diagnosis of urinary tract infections: quick reference guide for primary care. UK Health Security Agency (previously Public Health England) (2020), flowchart for women (under 65 years) with suspected UTI, page 6; table summary: diagnostic points for women under 65 years, page 7

Definitions of terms used in this quality statement

Urinary tract infection

An infection of any part of the urinary tract, usually by bacteria. For this statement, this definition excludes women with recurrent UTI (repeated UTI with a frequency of 2 or more UTIs in the last 6 months or 3 or more UTIs in the last 12 months) and women with a urinary catheter. [NICE's clinical knowledge summary on urinary tract infection (lower) - women, summary and UK Health Security Agency's (previously Public Health England) Diagnosis of urinary tract infections: quick reference guide for primary care, flowchart for women (under 65 years) with suspected UTI, page 6; table summary: diagnostic points for women under 65 years, page 7]

Key urinary symptoms

UK Health Security Agency currently indicates there are 3 key urinary symptoms:

  • dysuria (burning pain when passing urine)

  • new nocturia (passing urine more often than usual at night)

  • cloudy urine (urine cloudy to the naked eye).

[UK Health Security Agency's (previously Public Health England) Diagnosis of urinary tract infections: quick reference guide for primary care, flowchart for women (under 65 years) with suspected UTI, page 6]

Other excluding causes or warning signs

Other excluding causes are other possible genitourinary causes of urinary symptoms:

  • vaginal discharge

  • urethritis (urinary symptoms may be due to urethral inflammation post sexual intercourse, irritants, or sexually transmitted infection)

  • genitourinary symptoms of menopause/atrophic vaginitis/vaginal atrophy.

Warning signs are signs of:

[Adapted from UK Health Security Agency's (previously Public Health England) Diagnosis of urinary tract infections: quick reference guide for primary care, flowchart for women (under 65 years) with suspected UTI, page 6; table summary: diagnostic points for women under 65 years, page 7]

Equality and diversity considerations

When people with a learning disability present with urinary symptoms, diagnosing a UTI can be more difficult. People with a learning disability should have a discussion with a healthcare professional about urinary symptoms and UTI. Their support needs should be considered, for example, by giving longer appointments to allow more time for discussion and involving family members, carers or an advocate if the person wishes.