Improving the management of Recurrent Urinary tract infections in women under 30 – does conservative treatment really work?

Cameron L1, McPhee S1, Clark R1, Bekarma H1

Research Type

Clinical

Abstract Category

Conservative Management

Abstract 769
Non Discussion Abstract
Scientific Non Discussion Abstract Session 37
Conservative Treatment Infection, Urinary Tract Female Quality of Life (QoL) Pharmacology
1.NHS Ayrshire and Arran
Links

Abstract

Hypothesis / aims of study
Recurrent UTI’s (rUTI) in young women can be common and not only impact on quality of life (QoL) but also service provision within urology departments.  The extent to which these patients require investigation or medical therapies to be managed is variable.  Our department changed practice to manage these women in a nurse led service with medical input as required. 
The intention of this study was to reduce;
invasive investigations  
antibiotic use 
encourage self-management 
reduce attendance at consultant clinics
reduce surgical procedures
reduce radiology investigations 
Improve Quality of life  
Improve patient centred approach
Development of nurse-led services
Cost- effective health care provision
Study design, materials and methods
102 patients were referred to the service between March 2016 and 2018.  Following triage by urology consultants the patients were appointed to see a Nurse Continence Specialist.  They were assessed and data was collected from this assessment which included the following data;  
number of culture proven infections
specific triggers 
previous investigations 
post void residual, 
bowel habit,
lifestyle factors and weight
Dyspareunia  

All patients underwent US urinary tract. Only patients with  visible haematuria were referred for flexible cystoscopy.  All women were given written and conservative advice leaflets (BAUS cystitis, NICE IBS, bladder training, toilet positions, pelvic floor exercise, intercourse positions and lubrication advice).
Results
72 women aged 15 to 29 years attended for consultation.  Despite being referred as rUTI, 31 women had no culture proven samples and 16 had only 1 infection.  25 patients had at least 2 proven cultures with the maximum being 6.  
Triggers were identified in 33 women; 28 (85%) reported sexual intercourse, 2 alcohol consumption, 2 infrequent voiding and 1 had a high post void residual. 
All women has US KUB requested; 60 were performed, of which 49 (82%) were normal.  11 identified an abnormality but none were considered causative for rUTI.
16 women reported visible haematuria of which 13 had flexible cystoscopy – 10 (77%) were normal and 3 identified abnormalities - tight meatus, schistosomiasis and cystitis cystica.
In the 25 patients with 2 or more proven infections, we analysed results separately after 12 months of conservative interventions.  In those with 2 infections (14 patients) 86% had 0 or 1.  Patients with 3 infections (6 patients), 66% had 0 or 1.  Those with 4 infections (3 patients), 66% had no further and finally the 2 patients with 5 or 6 infections both patients had 0.  Only 3 of these 25 women required prophylactic, 0 required post coital and 1 obtained self-start antibiotics
13 out of these 25 (52%) women only required 1 appointment with the service and at 12 months 21/25 no longer require any contact (discharge or DNA).
Interpretation of results
See above
Concluding message
By changing practice we have significantly reduced the number of rUTI’s in this population which has significantly reduced the use  antibiotics within this cohort.  This has been achieved by appropriate assessment and developing an individualised  conservative management plan.  We have proven that invasive investigations are unnecessary. In our department we have  reduced the number of cystoscopy and dilatations significantly from 222 patients in 2013 to 69 in 2017. Within the consultant led clinics the number of new and review patient slots has been reduced thereby assisting with a reduction in waiting list times to comply with government targets. This has also impacted in a significant reduction in day surgery and in patient theatre utilisation for this group of patients.  This has also demonstrated a much more cost-effective approach.  The nurse continence team continues to develop this autonomous practice and allows patients to receive a holistic, self-directed approach to their own healthcare needs. This new approach has enabled the specialist nurses to continue with their on going professional development
Disclosures
Funding None Clinical Trial No Subjects Human Ethics not Req'd Audit of change in practice Helsinki Yes Informed Consent No