The Impact of Slow and Unreliable Tests
The challenge in hospitals is naturally different to primary care. Professor Peter Wilson of UCLH explained that, “compared to 10 years ago, I’m seeing five to ten times more multidrug-resistant organisms when culturing UTI in hospitals”.
Just over half of hospital UTIs result from E. coli, withgreater incidence of Enterococci, Staphylococci, Klebsiella, Pseudomonas and others causing infections than in primary settings. A particular challenge is the effective diagnosis of older patients; UTIs are a significant cause of mortality in the elderly population.[7]
Professor Wilson used the example of older women, for whom traditional urinalysis testing with a dipstick is far less accurate. Urinalysis is unable to distinguish between symptomatic and non-symptomatic UTIs. In fact, 61% of positive urinalysis specimens, when also sent to a lab to be cultured, turn out to be negative. For this reason, urinalysis is not recommended for patients over 65, instead doctors must rely on the cultures that need up to three days to produce a result and often have low specificity and sensitivity to uropathogens.
This delay in less-than-reliable test results again puts doctors in a position of using their best judgement to treat an infection with antibiotics, without knowing whether they are needed in the first place or, if there is an infection, which one they are fighting. Sadly, this is the grey-space in which AMR is proliferating. Hospitals need rapid tests, but they need them to be specific, to identify the quantity of bacteria in a sample and to understand the antibiotic susceptibility of that infection.
In community settings, the situation is even trickier. The limitations of diagnosis in older patients in hospital is naturally a challenge in the elderly care sector too. Here it is far harder to collect reliable mid-stream urine samples to produce useful diagnostic results. Care homes need to know if there is an active infection and if it could be life threatening. Since the tests we have are not adapted to the elderly population in the community, patients are unnecessarily referred from care homes to hospitals, just in case. This is not good for hospitals (in terms of beds and resources), but worse, it is not good for the elderly person whose life is disrupted significantly.
Studies have suggested admitting frail elderly people to hospital can be detrimental to their physical ability. There is a greater risk of contracting a hospital-acquired infection and it interrupts the existing relationships with carers. There is an increased risk of developing delirium, which can trigger dementia, possibly as a result of the stress of going into hospital. There is an economic impact too, people over 85 account for a quarter of all bed days in the NHS[8]. Rapid point-of-care tests have the potential to drastically improve diagnosis and disrupt unnecessary admission benefiting patients and hospitals alike.
Elsewhere in the community, Marco Motta, pharmaceutical advisor at NHS Kernow, spoke about pharmacy services tackling UTIs. GPs promote self-referral services in pharmacies where the pharmacist is authorised to provide antibiotic prescriptions. Since those pharmacies have no access to GP held records that may reveal a prior history of UTIs and their associated treatments, consultations take place without the right medical context. This lack of context increases the risk of incorrect prescriptions that promote drug resistance rather than eradicate infections.