Abstract
BackgroundStudies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. However, the joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated.MethodsThematic analysis of qualitative interviews with healthcare staff (n = 27) and older adult patients (n = 14) in two UK hospitals.ResultsInterviews featured a recurrent theme of discrepant understandings and gaps in communication or translation between different social groups in three key forms: First, between clinicians and older adult patients about symptom recognition. Second, between nurses and doctors about the use and reliability of point-of-care urinary dipsticks. Third, between nurses, patients, microbiologists and doctors about collection of urine specimens, contamination of the specimens and interpretation of mixed growth laboratory results. The three gaps in communication could all foster inappropriate diagnosis and antibiotic prescribing.ConclusionInterventions to improve diagnosis and prescribing for UTIs in older adults typically focus on educating clinicians. Drawing on the sociological concept of translation and interviews with staff and patients our findings suggest that inappropriate diagnosis and antibiotic prescribing in hospitals can be fuelled by gaps in communication or translation between different staff groups and older adult patients, using different languages and technologies or interpreting them differently. We suggest that interventions in this area may be improved by also addressing discrepant understandings and communication about symptoms, urinary dipsticks and the process of urinalysis.
Highlights
Urinary tract infections (UTIs) are the second biggest source of antibiotic prescribing in the UK and a major contributor to antimicrobial resistance (AMR) [1]
Our study offers the first investigation of the differing perspectives of nurses, doctors, older adult patients and microbiologists on the UTI diagnostic pathway, highlighting how these differences contribute to unnecessary antibiotic prescribing for UTIs
Our findings suggest that there are significant discrepancies between the perspectives on UTI diagnosis between different staff groups and older adult patients, which results in miscommunication that fosters unnecessary antibiotic prescribing
Summary
Urinary tract infections (UTIs) are the second biggest source of antibiotic prescribing in the UK and a major contributor to antimicrobial resistance (AMR) [1]. Diagnosing UTIs in older adults is challenging, as they frequently have asymptomatic bacteriuria (ASB), which is often inappropriately treated with antibiotics [2]. Qualitative study on hospital clinicians found that misdiagnosis of UTIs was driven by unreflective use of urinary dipsticks [8], and our parallel case series review of patient records found that 54% of older adults had a dipstick recorded [9]. Qualitative interview studies in care homes in UK and Canada have observed that nurses often diagnose UTIs based on vague symptoms, such as foul-smelling urine, and GPs prescribe antibiotics over the phone without seeing the patient [10, 11]. Studies have reported large scale overprescribing of antibiotics for urinary tract infection (UTI) in hospitalised older adults. Older adults often have asymptomatic bacteriuria, and clinicians have been found to diagnose UTIs inappropriately based on vague symptoms and positive urinalysis and microbiology. The joined perspectives of different staff groups and older adult patients on UTI diagnosis have not been investigated
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