Balancing treatment with resistance in UTIs

Abstract

Urinary tract infections (UTIs), defined by the presence of bacteria in the urine combined with clinical features such as urinary frequency or dysuria, affect 10–20% of women at some time in their lives. New draft guidance from the UK National Institute for Health and Care Excellence (NICE) aims to improve the rational prescribing of antibiotics for patients with lower UTIs and in a variety of special circumstances, such as recurrent UTIs, catheter-associated UTIs, prostatitis, and pyelonephritis. Although in most situations antibiotics are required, inappropriate treatment contributes to the growing problem of antibiotic resistance in UTIs, with more than a third of UK laboratory-confirmed Escherichia coli UTIs now resistant to key antibiotics. The guidelines suggest that all patients presenting with a lower UTI should be given advice on symptom management with paracetamol or ibuprofen and adequate fluid intake, and advised that there is no evidence for the benefit of cranberry products. In non-pregnant women, depending on symptom severity, the advice is now to consider a back-up antibiotic (taken only if symptoms worsen, or do not improve within 48 h), waiting for culture and susceptibility results before prescribing, or giving an antibiotic immediately. In all other groups, immediate antibiotics are advised. Trimethoprim and nitrofurantoin remain the first-line antibiotics of choice in all groups, except pregnant women. Pivmecillinam and fosfomycin are recommended as second-line choices for non-pregnant women who do not improve after 48 h. For women with recurrent UTIs, the NICE guidance now suggests that clinicians consider recommending D-mannose (a sugar, found naturally in many fruits, available in powder form), and vaginal oestrogen (for postmenopausal women) before considering single-dose antibiotic prophylaxis for exposure to triggers, or continuous antibiotic prophylaxis. This draft guidance is available for comment until June 5, and is expected to be formalised in January, 2019. Judicious use of antibiotics in common clinical situations is crucial for minimising antibiotic resistance, but also for the effective treatment of patients. Comprehensive guidance, such as this from NICE, will support clinicians in successfully achieving the balance between effective treatment and minimising resistance.