Informing NICE guidelines

One of our key aims is to bring about change in the way urinary tract infections are diagnosed and treated. The National Institute of Clinical Excellence (NICE) in the UK recently invited registered stakeholders to comment on proposed draft guidance on the treatment of urinary tract infections (UTIs): antimicrobial prescribing.

Currently there are no guidelines for chronic UTI with NICE noting: there is a ‘need for evidence-based guidance for recurrent UTIs’ but states that ‘no source guidance is currently available’.

As a stakeholder we responded to two of the draft papers: Recurrent Infections and the Lower Urinary Tract so that awareness of poor diagnosis and treatment in both primary and secondary care leading to chronic UTI is included in the revision of these guidelines.

Our comments included:

  • Our considerable concern over the known limitations of urine analysis and diagnosis including failure rates and tests that pre-dispose towards only fast growing bacterium. We noted that “mixed growth” culture with evidence of epithelial shedding, in the context of symptomatic, pyuric patients, point to a very significant pathological state, and should not be dismissed as “contaminated samples”.
  • Noting the serious shortcomings affecting the routine diagnostic tests health practitioners rely on to diagnose UTIs, with many health practitioners unaware of their frequent failures to detect or correctly identify pathogenic bacteria.
  • Advising on the lack of advice in the guidelines regarding the appropriate collection of urine samples and how to manage a situation where repeated samples are negative/show mixed growth/come back as possibly contaminated. Advice must be given to treat according to symptoms and clinical judgement.
  • Challenging the notion of recurrence of infection as opposed to continuing existence of original infection. Additionally, the failure to clearly understand the failure of previous treatment to successfully eradicate the original infection. This is clinically very important and is likely to become a lot more common with the increased use of shorter courses of antibiotics for standard treatment.
  • Recommendation that any patient with a history of recurrence of a UTI should receive a longer course of antibiotic treatment until symptoms completely resolve. Failure to completely eradicate infection increases the risk of complex or resistant bacterial infection developing.
  • Concerns over the use of prophylactic antibiotic when they are at sub-clinical doses as these can increase the risk of resistant bacterial infection developing if used when a pre-existing infection has not been fully eradicated.
  • Challenging the assumption of antibiotic resistance to higher dose antibiotics over prophylaxis.
  • Comments on the usage and dosage for D Mannose.
  • Disputing the validity of research studies used as a basis for recommendation of treatment dosage and length. Many are predicated around acute infection instances as opposed to continuing infection or in the case of one study for antibiotic duration based on post-menopausal women.
    Failure to mention the usage of Methenamine Hiprex in the long-term management of recurrent UTI. There is significant research suggesting it is an effective therapeutic option and an alternative to or addition to antibiotic use in this patient group.