Original Title: Initier des mesures diagnostiques en présence de signes et symptômes suggestifs d’une infection urinaire (cystite et pyélonéphrite) et initier un traitement pharmacologique de première intention pour la cystite chez un adulte ayant un déclin de l’autonomie fonctionnelle : Rapport en soutien au protocole médical national et au modèle d’ordonnance collective

Authors' objectives: The Ministère de la Santé et des Services sociaux (MSSS) has tasked the Institut national d'excellence en santé et en services sociaux (INESSS) with developing, updating and hosting the current national medical protocols and prescription templates. Following a prioritization exercise, the MSSS’s Direction nationale des soins et services infirmiers asked INESSS to develop a national medical protocol on initiating diagnostic measures following the identification of signs and symptoms suggestive of a urinary tract infection in the elderly and initiating first-line treatment, if applicable. However, the members of the advisory committee who assisted in the project proposed that the target population be expanded to include adults with functional autonomy decline possibly due to a major neurocognitive disorder, with no limitation to a particular living environment. In addition, they proposed that diagnostic measures and first-line pharmacological treatment be initiated in the target population with signs and symptoms suggestive of cystitis. However, only diagnostic measures will be initiated in the target population with signs and symptoms suggestive of pyelonephritis because of the complications associated with this type of infection.

Authors' results and conclusions: The literature search yielded 1189 items, 13 of which contain clinical practice recommendations for the management of urinary tract infections in adults. Eleven of the 13 publications are clinical practice guidelines, one is a clinical reference guideline, and one is a consensus document. One publication concerns exclusively the geriatric population, specifically, those living in residential and long-term care centres (CHSLDs). Their methodological quality was deemed adequate, based on the AGREE II GRS instrument. The present national medical protocol concerns persons 18 years of age or older who present with both functional autonomy decline and signs and symptoms suggestive of a urinary tract infection (cystitis or pyelonephritis). Urinalysis (a dipstick or microscopic) and a urine culture are the diagnostic measures to consider, regardless of which urinary tract infection is suspected. Indeed, although the literature consulted does not recommend a urine culture for cystitis with no risk factors for complications (with some exceptions), the advisory committee’s members felt that it is necessary, given the protocol’s target population. If a urine dipstick is used in the living or care setting and the result is positive, a request for a urine culture is submitted to the laboratory. If a urine dipstick is not available, a request for both a urinalysis and a urine culture will be submitted. Male sex, poorly controlled diabetes, and severe renal impairment (glomerular filtration rate < 30 ml/min/1.73 m2) are the risk factors for complications to be checked for in this protocol. According to the advisory committee, diabetes is said to be poorly controlled if the person has a glycated hemoglobin (HbA1c) ≥ 8.5% or repeated hyperglycemia (fasting blood glucose > 10 mmol/L or postprandial blood glucose > 14 mmol/L). Nitrofurantoin, fosfomycin (tromethamine), trimethoprim-sulfamethoxazole, and beta-lactams are some of the first-line treatments for cystitis with no risk factors for complications. Fluoroquinolones, beta-lactams and trimethoprim-sulfamethoxazole are recommended for the treatment of cystitis with one or more risk factors for complications. Since dysphagia is common in the protocol’s target population, alternative methods of administration are proposed for the drugs presented.   Conclusion The development of this national medical protocol and the collective prescription template is based on clinical data and clinical practice recommendations from the literature, which have been enhanced with the perspectives of different experts and clinicians, and with contextual information. The triangulation of data on the best available practices from the different sources consulted enabled the development of the protocol.

Authors' recommendations: A systematic review of clinical practice guidelines, expert consensus statements, consensus conference reports, guidance documents and any other items containing clinical recommendations was conducted in accordance with INESSS’s standards. The literature search was limited to items published between January 2017 and May 2020. The search parameters included, among other things, the elements that define a urinary tract infection, the health status assessment criteria, and the treatment modalities for a urinary tract infection. In addition, a manual literature search was conducted by consulting the websites of regulatory agencies, health technology assessment agencies, government bodies and professional associations in countries whose health-care system and clinical practices are similar to those in Québec. The national medical protocol and collective prescription template were developed in collaboration with an advisory committee. Its members provided information, expertise, opinions or perspectives that were essential for creating the protocol and template, this to ensure their scientific credibility, clinical relevance, and professional and social acceptability. The relevance of the contents and the overall scientific quality of the national medical protocol, the collective prescription template and the supporting report were assessed by four external reviewers: two nurses, a pharmacist and a urologist. In addition, a panel of future users consisting of nursing and pharmacy professionals was consulted to gauge the clinical relevance of the protocol and the corresponding prescription template and to assess their clarity and ease of use. The data were analyzed from the perspective of contextualizing Québec practice, using mainly legislative, regulatory and organizational contextual elements specific to Québec, and the experiential knowledge provided by the different stakeholders consulted

Project Status: Completed

URL for project: https://www.inesss.qc.ca/thematiques/medicaments/protocoles-medicaux-nationaux-et-ordonnances-associees/protocoles-medicaux-nationaux-et-ordonnances-associees/infections-urinaires.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/fileadmin/doc/INESSS/Ordonnances_collectives/Infection_urinaire/INESSS_Infection_urinaire_GN.pdf

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)