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Nurse prescribing, urinary tract infection and older men.

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VOL: 101, ISSUE: 12, PAGE NO: 69

Linda Nazarko, MSc, BSc, RN, FRCN, is consultant nurse - older people, Richmond and Twickenham PCT, and visiting senior lecturer, London South Bank University

Urinary tract infection (UTI) is rare in men who are 20-50 years old, and is considerably less common in men than in women, except in the first year of life and in older people. It may be associated with risk factors such as prostatic enlargement that may require further investigation (PRODIGY, 2002).

 

Urinary tract infection (UTI) is rare in men who are 20-50 years old, and is considerably less common in men than in women, except in the first year of life and in older people. It may be associated with risk factors such as prostatic enlargement that may require further investigation (PRODIGY, 2002).

 

 

Less than one per cent of young men (those aged under 60) develop UTIs compared to 10 per cent of older men (Wallach, 2001).

 

 

This paper is a response to the difficulties that such cases present and explores why ageing and other factors increase the risk of infection.

 

 

Urinary tract infection Urine is normally sterile and a UTI is defined as ‘bacterial growth greater than or equal to 105 colony forming units/ml in a clean voided mid-stream urine specimen’ (Kontiokari et al, 2001).

 

 

UTI can be symptomatic, asymptomatic, complicated or uncomplicated. A symptomatic UTI is identified by the presence of clinical symptoms that can be attributed to the presence of bacteria in the urinary tract. This may present as an acute uncomplicated UTI or an acute non-obstructive pyelonephritis (Bissett, 2004).

 

 

Diagnosis of UTI - A diagnosis of urine infection should not be based solely on microscopy, culture and sensitivity testing of a urine sample.

 

 

There are differences between bacteriuria (bacteria in the urine) and infection. Studies indicate that certain groups of people - especially women, older people and people with catheters - may have asymptomatic bacteriuria (Brocklehurst et al, 1997).

 

 

These groups have no symptoms of urine infection and do not require treatment. Several factors may lead to a person with bacterial growth in a urine specimen being inappropriately treated for UTI. These include:

 

 

- Poor technique in collecting specimens;

 

 

- Collecting specimens inappropriately, for example, from catheterised patients;

 

 

- Poor handling of specimens, for example, bacteria in a urine specimen will multiply if it is stored at room temperature for several hours.

 

 

The dipstick urine test for nitrite or leucocyte esterase helps to confirm clinical impressions of a UTI. However, PRODIGY (2002) suggest that a urine specimen should be sent for culture in men suspected of having a UTI as the evidence supporting the use of the dipstick urine test in men is poor (see p60).

 

 

Researchers have found that 46 per cent of specimens taken from older people are contaminated and urge great caution in interpreting infection based solely on urinalysis using urine testing sticks in such patients (Gazzani at al, 2001).

 

 

Symptoms of UTI This condition can cause one or more of the following symptoms:

 

 

- Unusually frequent urination;

 

 

- An intense urge to urinate;

 

 

- Dysuria - pain, discomfort or a burning sensation during urination;

 

 

- Pain, pressure or tenderness in the area of the bladder (midline, above or near the pubic area);

 

 

- Urine looks cloudy, or smells foul or unusually strong;

 

 

- Fever, with or without chills;

 

 

- Nausea and vomiting;

 

 

- Pain in the side or mid to upper back;

 

 

- Nocturia - awakening from sleep to pass urine;

 

 

- Onset of enuresis (bedwetting) in a person who has usually been dry at night.

 

 

Predisposing factors for older men are shown in Box 2 (Stamm and Raz, 1998).

 

 

Treatment
A sample for culture and sensitivity is not required to treat simple, uncomplicated symptomatic UTIs in healthy, young adult females (PRODIGY, 2004).

 

 

If an infection does not respond to standard antibiotic therapy then a specimen should be collected and culture and sensitivities should be obtained.

 

 

Current guidance indicates that young men and all older people who have UTIs should have a urine specimen sent for culture and sensitivity before starting treatment with a first-line antibiotic such as trimethoprim, nitrofurantoin or cefalexin (PRODIGY, 2002).

 

 

Antibiotic therapy is reviewed when the results of the urine culture are received (PRODIGY, 2002). The infecting organism in 77 per cent of urinary infections is Escherichia coli (Kahlmeter, 2003). The need for further investigations of risk factors associated with UTI in men should also be assessed (Box 2).

 

 

Research indicates that three days of antibiotic therapy is sufficient to treat younger women but men should receive a course for seven days (PRODIGY, 2004; 2002). There is debate about the duration of therapy for older people (Lutters and Vogt, 2000).

 

 

Many clinicians believe that older people require a longer course of treatment. PRODIGY guidance (2004; 2002) recommends seven days of therapy for older people. Recent research suggests that shorter courses are equally effective and better tolerated (Vogel et al, 2004).

 

 

Antibiotic resistance is a growing problem. Researchers investigating resistance internationally found that 14.8 per cent of E. coli UTIs are resistant to trimethoprim and 40 per cent of enterobacteria are resistant to nitrofurantoin. Resistance is highest in countries where antibiotics are most widely used and inappropriate prescribing contributes to this problem (Kahlmeter, 2003).

 

 

The limitations of nurse prescribing
There are 2,400 extended formulary nurse prescribers in the UK who can prescribe over 180 prescription-only medicines, plus a range of pharmacy-only medicines and medicines from the general sales list.

 

 

Nurse prescribers are limited to prescribing for a range of conditions, for example, it is possible to prescribe antibiotics for females with an uncomplicated UTI but not for men.

 

 

This can mean that a nurse prescriber can assess a patient, diagnose two problems but only have the ability to treat one of those conditions. The prescriber may then have to call a doctor to treat the second condition and this can lead to delays in treatment and fragmentation of care. In some cases the prescriber may be able to use a patient group direction. However, preparing PGDs requires considerable work and some prescribers may not have access to them.

 

 

Supplementary prescribing is of value to nurses who treat patients who have a clearly defined condition such as diabetes.

 

 

The prescriber can use supplementary prescribing to prescribe a specific drug such as insulin or to alter doses within specific agreed parameters. They are of limited use to nurses who may have to deal with a range of acute and unpredictable problems.

 

 

Current legislation makes it difficult for prescribers to provide holistic care and it makes it difficult to use clinical judgement and to provide timely, sensitive, responsive care (Box 1). Current legislation discourages nurses from becoming prescribers because of its limitations and because nurses find that they have a greater level of clinical autonomy by using PGDs.

 

 

If nurses are to fulfil their potential (Department of Health, 1997) they must learn to engage with policy makers and argue that nurse prescribing needs to change if we are to provide a service that is responsive to patient needs.

 

 

Conclusion
Under the present system I can prescribe oral contraception, hormone replacement therapy and acne treatments. My knowledge of these is scant, as these issues do not tend to concern older people. I am bound by the NMC’s code of conduct to work within my sphere of competence.

 

 

It would be so much easier if the DoH was brave and opened up the BNF to nurse prescribers so that we could prescribe freely within our sphere of competence and meet our patients needs (see Footnote).

 

 

Footnote
A Department of Health consultation is currently looking at future options for nurse prescribing. Full details are available at the www.dh.gov.uk website. The consultation closes on 23 May.

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