Epidemiology of UTI

Urinary tract infection (UTI) is the second most prevalent severe health problem among public population with increasing rate of morbidity and mortality affecting women candidates in young as well as old age. Young boys are also victims to these microbial infections; approximately 150 million cases are reported globally with 10 million affected in United States. Urinary tract infections, as justified by National Institute for Health Care and Excellence (NICE), are bacterial infections which are majorly manifested as complicated form with clinical variability in symptoms and corresponding interpretation and resultant treatment. Various clinical guidelines are developed to promote better practice in clinical handling of patients in both primary as well as secondary care settings. The guidelines are being updated with changing evidences and requirements to improve patient handling.

Urinary tract infections are caused by both gram positive and gram negative bacteria, the most prevalent uropathogenic bacteria being Escherichia coli. Enterococcus and Klebsiella pneomoniae have shown a significant incidence in infection. Candida albicans show a near prevalence to cause urinary tract infection (Flores-Mireles et al., 2015). Indwelling catheters and structural abnormalities of the tract are common in complicated UTI.

UTI affects both upper and lower tracts with a change in micro biome of the tract. Bcaterial colonization ascends through the ureters limiting the flow of urine and reaches the urinary bladder where they replicate and generate a biofilm production on the bladder wall (Walsh & Collyns, 2017).

UTIs are the most prevalent and significant cause of infant morbidity and also among people of old age. United States have been reported with increased societal burden with millions of cases reported in the last 5 years (Schaeffer & Nicolle, 2016). Recurrences of bacterial infections with renal damage and septic shock are common if left untreated and undiagnosed.

Heterogeneity in clinical symptoms of urinary tract infection necessitates development of treatment guidelines to prevent the increase in colonization by antibiotic resistant bacteria. Primary care clinical guidelines have been developed and implemented with better approach in patient handling. Clinical practice guidelines have majorly contributed to all sectors of health care industry. These guidelines are developed with the goal of promoting and improving the quality of patient care. These guidelines are developed on the basis of symptomatic interpretation of clinical manifestations (Kang et al., 2018). Clinical practice guidelines undergo modifications based on their previous applications and results. Practice guidelines are beneficial in regulating the economic costs in health care settings. Guidelines are revised and updated in compliance with previous evidences of its applications. Guidelines introduce technological applications aimed to reach efficient patient care. Realistic clinical guidelines provide better ways to measure the efficacy of primary health care.

National Institute for Health and Care Excellence (NICE) provides an outline of clinical guidelines for urinary tract infection to be practiced for quality patient care by health professionals. The following algorithm outlines the guideline 47 of NICE to treat bacterial infections of the urinary tract, both complicated and non-complicated forms.

                   

                                                             Figure 1: NICE 47 guideline

Pathophysiology of UTI

                                                            (Source: created by Author)

               

                                                              Figure 2: NICE 47 guideline

                                                              (Source: created by Author)

The NICE guidelines for urinary tract infection are mainly focusing on the diagnosis of the infection with a concern on the management of the clinical course. UTI often show a recurring episode in young children and women. These guidelines provide an efficient practice approach in managing the treatment of recurrent infections in these patients. NICE guidelines entail a detailed approach of treatment considering wide array of risk factors that are responsible for the pathogenesis of urinary tract infection (Simpson, 2017). These clinical guidelines are based on highly specific range of diagnostic symptoms. Categorized specific treatment approaches are mentioned for infants, children and young people.

A more strengthening factor of these guidelines is that, they have major reliance on current evidences of clinical trials of urinary tract infection among patients with non-complicated and complicated forms of infection.

The guidelines as well as the algorithm provide a directive approach to the primary care health officials. It has a specific inclusion criteria about whom to apply these guidelines; what diagnostic criteria should be focused for assessment is also outlined in detail. The guidelines provide recommendations on urine testing strategies as primary treatment for children reported with unexplained symptomatic criteria (Kanters et al., 2016). Significant recommendations are provided by the guideline to prevent episodes of recurrence of infection among young children.

The NICE guidelines have shown significant efficacy while treating cases of recurrent infections in young children. The recommendations have shown e reduction in recurring infections in young boys. NICE targeted self-care practice approaches to reduce prescribing antibiotics to UTI patients, an efficient strategy to inhibit the development of drug resistant bacteria (Drummond, 2016). Revision of guidelines have highlighted that, the intensity of severity needs to be addressed from patients during diagnosis before prescribing antibiotic treatment (Yue et al., 2014). Again, this approach has shown a promising outcome on patient treatment and care.

NICE guidelines are significant and show a promising trend towards primary treatment of patients. The guidelines mainly focus on infants and young children; old aged people are not taken into account while developing and regulating these guidelines.  UTI have also been reported among old people as both complicated and non-complicated form. The guidelines need to be revised and consider the evidences of clinical trials of old people (Montini & Herewitt, 2015). This guideline can be used as a means of reference for treatment of infants and young children, at a level of high efficacy. A high percentage of women candidates suffer from UTI, but this guideline outlines no measures to provide treatment approach significant for women (Brubaker et al., 2014). Revision is necessary to incorporate additional clinical guidelines supporting the women population as well as the old people. Lifestyle variations and unhygienic insanitation bring about this bacterial infection. Focus should also be on insanitation while revising and modifying the guidelines.

Morbidity and Mortality

United States have previous records of hospitalizations of females and children diagnosed with urinary tract infection. Around 50000 hospitalization cases per year have been reported, of which majority of patients were females and infants, lower percentage belonged to young children (Chaudhari, Monuteaux & Bachur, 2018). Hospitalization charges are huge in United States due to high throughput technologies like imaging being used for treatment. Over the recent five years, the charges of diagnosis and hospitalization have increased way beyond. Statistical analysis of economic burden have been performed among patients admitted to hospitals with UTI in United States; the increase in aggregate hospital and treatment costs are not in commensurate with the increasing hospital admissions. Hospital costs increase by approximately $1200 per year per hospitalization in United States (Spencer et al., 2013). The States is witnessing continuous immigration, therefore, percentage of population getting the UTI can be varying with time. Reduction of economic burden and lowering of incidence of infection should be focused while regulating the guidelines to suit the needs of population with lower income. More studies need to be performed and evidences need to be considered to design and implement in better ways to provide quality primary treatment (Wu et al., 2013).

Clinical practice guidelines are intended to improve the treatment of patients. Nursing officials and health care practitioners are involved in providing quality care to patients considering these guidelines. Health officials and nurses have evolved in their strategies to reach out to the patients and provide beneficial medical care. Revision and updating of clinical guidelines are done to improve the health service programs. Whether these guidelines are appropriate or not and meeting the criteria considered, certain plans should be designed to evaluate the appropriateness of the outcome of guidelines. Success of clinical practice guidelines comes with evaluation strategies. Clinical practice guidelines are revised and updated, thereafter disseminated for primary treatment benefit. These evaluation plans target the developmental method of guideline to assess its appropriateness (Chua et al., 2017). Strategies should be developed and implemented to check whether the clinical practices following the revised guidelines are having a positive impact on the health status of the patients. Evaluations can be done in many ways; to assess the development of guidelines, to target the treatment procedures, to check the follow up scheme of patients after receiving medical care are some of the focus points of evaluations.

Following measures can be employed to assess whether the updated guidelines are positively impacting the health scenario of patients.

• To check the status of infection of patients with UTI on a monthly basis
• To recommend a change in medication dosage to those patient s who are being prescribed antibiotics for treatment
• To provide a telephonic interaction on a weekly basis to keep a track of the disease progression
• To go for a follow up at home to check if there are side-effects of the treatment methods provided with guidelines in consideration
• To make partnership with patient family for routine checkup and further medication consultation

• Nursing and health care officials are employed to provide quality primary treatments to patients with urinary tract infection.
• Females and young children are more prevalent in getting the bacterial infection.
• Clinical guidelines are integral to improve treatment strategies for quality primary care.
• Studies and evidences should be considered to constantly revise and update the guidelines to provide better improvement measures in treatment management.

Conclusion

Urinary tract infection occurs as the most common public health problem which affect majorly women and young children. Infants are also affected at a moderate percentage. Clinical practice guidelines are developed to enhance the treatment procedures and improve the quality of patient care. Nursing and health care providers are adapting to the various improvement strategies to provide to the patients. Strong evidences are still required to further regulate the guidelines and achieve high improvement in treatment success. Evaluation programs need to be designed to assess the success of the revised guidelines. Revision and updating of guidelines should be done with a focus on reducing the economic burden.

References

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Chaudhari, P. P., Monuteaux, M. C., & Bachur, R. G. (2018). Management of Urinary Tract Infections in Young Children: Balancing Admission with the Risk of Emergency Department Revisits. Academic pediatrics. doi.org/10.1016/j.acap.2018.05.011

Chua, M., Ming, J., Dos Santos, J., Chang, S. J., Silangcruz, J. M., Bayley, M., & Koyle, M. (2017). Mp61-12 A Critical Review of Recent Clinical Practice Guidelines on the Diagnosis and Management of Paediatric Urinary Tract Infection Using the Agree Li TooL. The Journal of Urology, 197(4), e803. doi.org/10.1016/j.juro.2017.02.1870

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Kanters, S., Ford, N., Druyts, E., Thorlund, K., Mills, E. J., & Bansback, N. (2016). Use of network meta-analysis in clinical guidelines. Bulletin of the World Health Organization, 94(10), 782.  doi: https://dx.doi.org/10.2471/blt.16.174326

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Schaeffer, A. J., & Nicolle, L. E. (2016). Urinary tract infections in older men. New England Journal of Medicine, 374(6), 562-571.doi:10.1056/nejmcp1503950

Simpson, P. (2017). Long-term urethral catheterisation: guidelines for community nurses. British Journal of Nursing, 26(9), S22-S26. doi.org/10.12968/bjon.2017.26.9.S22

Spencer, J. D., Schwaderer, A., McHugh, K., & Hains, D. S. (2013). Pediatric urinary tract infections: an analysis of hospitalizations, charges, and costs in the USA. Pediatric Nephrology, 25(12), 2469-2475. doi 10.1007/s00467-010-1625-8

Walsh, C., & Collyns, T. (2017). The pathophysiology of urinary tract infections. Surgery (Oxford), 35(6), 293-298. doi.org/10.1016/j.mpsur.2017.03.007

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