Development of an information leaflet and diagnostic flow chart to improve the management of urinary tract infections in older adults: a qualitative study using the Theoretical Domains Framework

BACKGROUND: Urinary tract infections (UTIs), older age, lack of access to health care, and recent antibiotic use are risk factors for Escherichia coli (E. coli) bloodstream infections. AIM: To explore the diagnosis and management of UTIs in primary care to inform the development of an information leaflet, a diagnostic flow chart, and recommendations for other resources. DESIGN & SETTING: The study had a qualitative design and was undertaken in primary care settings and care homes. METHOD: Interviews and focus groups were informed by the Theoretical Domains Framework (TDF) with 31 care home staff, three residents, six relatives, 57 GP staff, and 19 members of the public. An inductive thematic analysis was used and themes were placed in the Behaviour Change Wheel (BCW) to recommend interventions. RESULTS: Care home staff were pivotal for identifying suspected UTI, alerted clinicians to symptoms that influenced prescribing decisions, and reported confusion or behavioural changes as the most common diagnostic sign. Care home staff lacked knowledge about asymptomatic bacteriuria (ASB) and sepsis, and incorrectly diagnosed UTI using urine dipsticks. GP staff used urine dipsticks to rule out UTI and reported that stopping dipsticks would require a culture change, clear protocols, and education about ASB. Many prescribers believed that stopping urine dipstick use should help to reduce antibiotic use. CONCLUSION: A consistent message about ASB and UTI diagnosis and management in older adults should be communicated across the care pathway. Resource development should increase capability, motivation, and opportunity to improve management of suspected UTIs. An educational leaflet for older adults and a diagnostic flow chart for clinicians have been developed, and recommendations for interventions are discussed.