Estimating the true impact of urinary tract infections

Abstract

Half of women suffer at least one symptomatic uncomplicated urinary tract infection (UTI) ( Platt and Keating, 2007 ) at some point in their lives, usually following superficial infection of the bladder mucosa with Escherichia coli ( Zalmanovici Trestioreanu et al, 2010 ). Although serious complications are rare, UTIs commonly compromise quality of life, work and daily activities ( Platt and Keating, 2007 ). Nevertheless, physicians may underestimate the impact of UTIs, while differences in disease ‘models’ between patients and health professionals can create confusion. For instance, describing the female urethra as short led ‘some women to believe that they were deformed’ ( Platt and Keating, 2007 ). Furthermore, most women ‘struggle’ to discuss the signs, symptoms and natural history of UTIs ( Leydon et al. 2010 ). Cotrimoxazole, fluoroquinolones, beta-lactams and nitrofurantoin broadly show equal efficacy at achieving short- and long-term symptomatic cures in uncomplicated UTIs ( Zalmanovici Trestioreanu et al, 2010 ). However, 8–15% of women with UTIs require another course of antibiotics within 4 weeks ( Hummers-Pradier and Kochen, 2002 ), and 40–50% experience recurrence within a year ( Ejernæs, 2011 ). When choosing between antibiotics, prescribers should consider likely susceptibility, adverse events, resistance and patient preference ( Zalmanovici Trestioreanu et al, 2010 ). Pregnant women should avoid trimethoprim either alone or combined with sulphonamides whenever possible ( Sivojelezova et al. 2003 ). In contrast, since the introduction of nitrofurantoin in 1952, ‘its suitability in human pregnancy has been well documented’ ( Macrodantin SPC, 2010 ). Rashes are more common with co-trimoxazole than with nitrofurantoin ( Zalmanovici Trestioreanu et al, 2010 ). In addition, during long-term treatment, fewer patients taking modified-release nitrofurantoin developed drug-related adverse events than with co-trimoxazole or trimethoprim ( Spencer et al. 1994 ). Resistance to co-trimoxazole, and probably to fluoroquinolones, is increasing ( Zalmanovici Trestioreanu et al, 2010 ), in contrast to the low levels seen with nitrofurantoin ( Nicolle et al, 2006 ). In conclusion, nitrofurantoin is a rational firstline empiric treatment for uncomplicated UTIs and ‘more widespread use is justified from a public health perspective as a fluoroquinolone-sparing agent’ ( Zalmanovici Trestioreanu et al, 2010 ).