Treatment failure of UTIs in primary care

BMJ letter from Professor Malone-Lee, Emeritus Professor of Medicine at UCL on the Duration of antibiotic treatment for common infections in English primary care: cross sectional analysis and comparison with guidelines reveals microbiological and symptomatic failure rates of between 28% and 37% of patients treated with 3 or 14 days of treatment.

The management of UTI in primary care

I applaud the attention being paid to UTI and the important observation by Gharbi et al that delayed treatment may cause unwanted consequences. I agree that it is important to respond AMR by rationalising the use of antibiotics. Pouwles et al, do well to raise the matter of treatment duration. However, I believe that in our enthusiasm to address AMR we are failing in our responsibilities to a significant subset of exceptional patients.

The key studies that drive the 3-day versus 14-day treatment were collated in an important meta-analysis by Milo et al (2005) [1]. You have to go to the tables at the back of the full report and extract the data manually to learn that the trials recorded microbiological and symptomatic failure rates of between 28% and 37% of patients treated with 3 or 14 days of treatment.

The MSU culture is promoted for UTI management despite it being discredited [2-5] with dipsticks found to be similarly flawed [6, 7]. In our enthusiasm for limiting antibiotic consumption we may be failing a significant minority. We dismiss their treatment response failures and persistent symptoms because negative results from discredited tests falsely reassure. We sentence these poor people to life-changing, painful chronic lower urinary tract symptoms, denying them legitimate treatment to comply with guidelines informed by dud tests. These are modern-day, sacrificial lambs, placed on the altar of the god of AMR. If you doubt this, pull out the Digital NHS data for hospital admissions and outpatient attendances for cystitis and interstitial cystitis and plot them on a time axis. Why do we see such a worrying rise in the number of cases?

1. Milo, G., et al., Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane.Database.Syst.Rev., 2005(2): p. CD004682.
2. Hilt, E.E., et al., Urine is not sterile: use of enhanced urine culture techniques to detect resident bacterial flora in the adult female bladder. J Clin Microbiol, 2014. 52(3): p. 871-6.
3. Price, T.K., et al., Urine trouble: should we think differently about UTI? Int Urogynecol J, 2017.
4. Wolfe, A.J., et al., Evidence of uncultivated bacteria in the adult female bladder. J Clin Microbiol, 2012. 50(4): p. 1376-83.
5. Sathiananthamoorthy, S., et al., REASSESSMENT OF ROUTINE MIDSTREAM CULTURE IN DIAGNOSIS OF URINARY TRACT INFECTION. J Clin Microbiol, 2018.
6. Kupelian, A.S., et al., Discrediting microscopic pyuria and leucocyte esterase as diagnostic surrogates for infection in patients with lower urinary tract symptoms: results from a clinical and laboratory evaluation. BJU Int, 2013. 112(2): p. 231-8.
7. Khasriya, R., et al., The Inadequacy of Urinary Dipstick and Microscopy as Surrogate Markers of Urinary Tract Infection in Urological Outpatients With Lower Urinary Tract Symptoms Without Acute Frequency and Dysuria. J.Urol., 2010. 183(5): p. 1843-1847.

Read the letter on the BMJ website