Hypothesis / aims of study
Urinary tract infections (UTIs) are the most common outpatient infections that are referred to the urologist and it represent a substantial financial burden on the health care system.
According to ICS, Urinary Tract Infection is defined as the finding of microbiological evidence of significant bacteriuria and pyuria usually accompanied by symptoms such as increased bladder sensation, urgency, frequency, dysuria, urgency urinary incontinence, and/or pain in the lower urinary tract (1).
In April 2021, we established a multidisciplinary complex UTI clinic in collaboration with specialist nurses and microbiologists with an aim of improving these patients’ symptoms and quality of life (QoL) with a holistic approach.
Study design, materials and methods
A prospectively maintained database of all 83 patients {(median age 54 years (16-85 year) and (M: F of 1:13)} who were referred to our clinic, within a one-year period were reviewed. Patients’ demographics, significant co-morbidities, number of infections per year, urine culture result (causative bacterial organism and antibiotic sensitivities), investigations performed, and treatment outcome were recorded. Pre-treatment QoL and post-treatment PGI-I (Patient global impression of improvement) Scale were measured. All clinics were supported by specialist nurses and microbiologists and a complex UTI multidisciplinary team meeting was arranged on monthly basis.
Results
Outcomes are detailed in table 1.
A total number of 83 patients were referred to our complex UTI clinic either by General Practitioners (GP) or by fellow Urologist, our record showed a distribution of male: 6 (7.3%) and female: 77 (92.7%) Age distribution showed a minimum age of 17 years and a maximum age of 85years. The mean age was 52.42 with a median of 54 years. Escherichia Coli (51.8%) was identified as the most common causative organism and this is consistent to the findings in other studies. Subgroup of our patients was further investigated with USS renal tract, CT Urogram, and cystoscopy to rule out underlying pathology. Abnormal renal USS, CTU, and cystoscopy were reported in 8.3%, 9.5%, and 8.3% respectively including diagnosis of bladder (1) and renal cancer (2).
All patients received verbal and written information on general cystitis prevention measures. 13 (15.6%) patients did not respond to oral treatment and hence received intravesical treatment. Pre-treatment 50% of patients report a significant impact on their QoL. Over 80% of patients had good improvement on the PGI-I scale after the treatment
Interpretation of results
In our complex UTI clinic, most of our patients were females and they account for 92.7% of patients. Significant comorbidities were noted in 29 patients (36%) and these co-morbidities were significantly linked to the recurrent UTIs in these patients. On evaluation of urine samples obtained, Escherichia coli was the commonest organism isolated and Nitrofurantoin was the most sensitive antibiotic. Patients seen in our clinic were discussed in the complex UTI clinic MDT and the appropriate treatment plan was agreed and this was discussed with the patient either via a face to face or a telephone clinic appointment. All our patients were educated on general cystitis preventive measures. Other treatment used were low dose prophylactic antibiotics based on urine culture and sensitivity result, methenamine hippurate and estrogen cream for women with atrophic vaginitis. Patients who didn’t improve on these initial treatments either received glucose aminoglycans (GAG) replacement therapy or intravesical Gentamicin based on MDT recommendation.
Overall, significant improvement in symptoms and quality of life was observed for the patients managed at complex UTI clinic using a multidisciplinary approach which involved urologist, specialist nurses and microbiologist.