Urinary tract infection in primary care
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c657 (Published 05 February 2010) Cite this as: BMJ 2010;340:c657
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There is too little results in avoiding unnecessary antibiotic use,
despite that antibiotic resistance is an important public health concern
and that antibiotics are one of the most commonly prescribed drug classes
worldwide.
For urinary tract infection in primary care, Mangin rightly focused on
providing treatment guidelines and decision support to physicians but he
evoked confusing notions such as “therapeutic influence” and “placebo
effect”. We believe he simply missed the overestimation of the benefit
.(1)
Overestimation of the benefit is well characterized for cancer screening
programs: people overestimated the mortality reduction from screening by
at least one order of magnitude and health pamphlets tended to increase
rather than reduce overestimation.(2) We will not discuss overestimation
by doctors.
France, which had the highest rates of antibiotic use and pneumococcal
resistance in Europe, developed a sustained and multifaceted campaign. It
used mass media (the message was that “Antibiotics are not automatic”) as
well as targeting physicians (one-on-one educational sessions known as
“academic detailing” and promotion of the streptococcal rapid antigen test
plus treatment guidelines for viral respiratory tract infections).
Antibiotics prescriptions decreased by 27 %.(3) This confirmed previous
campaigns in others counties (eg. Belgium).
Physicians develop mindlines and citiszen have perceptions. Well-
coordinated national efforts are mandatory to get rid of them and avoid
unnecessary treatments.
1 Mangin D. Urinary tract infection in primary care. BMJ
2010;340:c657
2 Gigerenzer G, Mata J, Frank R Public knowledge of benefits of
breast and prostate cancer screening in Europe. J Natl Cancer Inst
2009;101:1216-20
3 Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Boëlle P-Y
et al. Significant reduction of antibiotic use in the community after a
nationwide campaign in France, 2002–2007. PLoS Med 2009;6:e1000084.
Competing interests:
None declared
Competing interests: No competing interests
I believe this editorial will be one of the most influential papers of
this decade. What it demonstrates is the manner of the attending
clinician is of utmost value. That this is the case in a common and
uncomplicated condition, makes one wonder just how important the role of
the attending clinician's persona is, in more complex conditions.
In this era of protocol driven pathways, the role of the attending
doctor seems to have been sidelined. This article is a timely reminder
that the value of a clinician providing therapy is greater than just being
an access route to the therapy provided.
Competing interests:
None declared
Competing interests: No competing interests
I read your editorial and the three research papers with
interest and curiosity. We were taught to use Mist. Pot. Cit
for all UTI's in women as a way to abolish the symptoms and
avoid the need for antibiotics. Nowadays sachets of various
citrates are available over the counter, but have no place in
your editorial nor in the three articles on management in
primary care. Have I missed something since I specialised in
psychiatry? From time to time I have advised citrates for
women and always with success. I have also berated junior
staff for using antibiotics as a first line, they seem not to
have heard of citrates at all and have suggested cranberry
juice. I now feel like a latter day Rip van Winkle, is it time
that I woke up?
Michael R. Pokorny
Competing interests:
None declared
Competing interests: No competing interests
The competing demands of providing the best outcomes for the
individual
while protecting population outcomes (such as antibiotic resistance)
within a
resource limited system epitomise General Practice. What we do and how we
provide care impact on both individual and population but quantitative
evidence inevitably favours the population while qualitative evidence
shifts
the balance back to the individual in the consulting room.
Quantitative results from a qualitative study are perhaps unreliable
but, since
they are published, they should be addressed. These results (1) indicate
three groups of patients who report urinary tract symptoms to their GP.
The
first with a median duration of symptoms of 2-3 days, the second with a
median duration of 7 days and the third with a median duration of 3 weeks.
There is perhaps a fourth group who do not present at all.
This observation might be explained by the patients being either
“early
presenters” or “delayed presenters”, in which case the first (unseen)
group
would be delayed presenters with self-limiting disease who have no need to
present, the second would be early presenters and the third, delayed
presenters where self-imposed delay had been unsuccessful and a further
strategy was required. The final group of late presenters is a confounding
group that all front line GPs are familiar with. Unfortunately the linked
quantitative studies (2,3) (perhaps unwisely) preceded the qualitative
studies
and so women presenting with urinary symptoms were assumed to be an
homogenous group: the qualitative data does not appear to support this
assumption.
If this analysis is correct, then duration of symptoms would support
a
strategy of dipstick testing at up to 3 days of symptoms, giving
antibiotics to
positives and a delaying strategy to negatives. Over 5 days
immediate antibiotics appear to be indicated.
Early presenters should have an approach that emphasises belief and
understanding, delayed presenters should be validated for delaying. Late
presenters may need a different approach not addressed by this evidence.
1. Leydon GM, Turner S, Smith H, Little P. Women’s views about
management
and cause of urinary tract infection: qualitative interview study. BMJ
2010;340;c279.
2. Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al.
Effectiveness of five different approaches in management of urinary tract
infection: randomised controlled trial. BMJ 2010;340:c199
3. Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, et
al.
Presentation, pattern, and natural course of severe symptoms, and role of
antibiotics and antibiotic resistance among patients presenting with
suspected uncomplicated urinary tract infection in primary care:
observational
study. BMJ 2010;340:b5633
Competing interests:
None declared
Competing interests: No competing interests
MSSU still has a role in the management of urinary tract infections in primary care.
We read this article with much interest. Dr Mangin's conclusion that
'sending midstream urine samples for testing is clearly unhelpful and
expensive' is misleading and requires further clarification. This
conclusion is primarily based on the study by Little et al comparing the
effectiveness of five different approaches in the management of urinary
tract infections (UTI)[1]. The study recruited 309 patients from 62
practices over a 2 year period, with an average of less than three
patients per practice per year, a rather low figure when it is widely
known that around 10% of pre-menopausal, non-pregnant women will present
with acute uncomplicated cystitis.
Determination of a urine culture is not necessary in women with
symptoms and positive dipstick, and anti-microbial treatment should not be
delayed. Does this mean that the midstream urine (MSU) no longer has a
place in primary care?
Firstly, empirical antibiotic treatment is based on the local
susceptibility profile of the uropathogen, and 20% of uropathogens are now
resistant to trimethoprim. A trend away from culturing patients will
compromise knowledge of local resistance patterns. Secondly, 20-30% of
women who have a UTI, will have at least one recurrent UTI, either due to
bacterial persistence or re-infection [2]. Clearly, previous urine culture
will help direct subsequent therapy. Thirdly, an unspecified but
significant proportion of women with lower urinary tract symptoms due to
an overactive bladder, may be mis-diagnosed as having a UTI or recurrent
UTI, when a simple urine culture could disambiguate the two conditions.
Furthermore, persistence of significant haematuria on urine microscopy,
following resolution of symptoms, may require additional urological
investigations.
Though a positive MSU is not mandatory prior to commencement of
treatment in women with a UTI, it has a distinct and vital role in the
management of this common and debilitating conditon, and we ignore it at
our peril.
1. Little P, Moore MV, Turner S, Rumsby K, Warner G, Lowes JA, et al.
Effectiveness of five different approaches in management of urinary tract
infection: randomised controlled trial. BMJ 2010;340:c199.
2. Sanford JP. Urinary tract symptoms and infection. Annu Rev Med
1975;26:485-98
Competing interests:
None declared
Competing interests: No competing interests