Urinary Tract Infection In Primary Care Research Articles

D-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women

Recurrent urinary tract infection (UTI) is a common debilitating condition in women, with limited prophylactic options. d-Mannose has shown promise in trials based in secondary care, but effectiveness in placebo-controlled studies and community settings has not been established. To determine whether d-mannose taken for 6 months reduces the proportion of women with recurrent UTI experiencing a medically attended UTI. This 2-group, double-blind randomized placebo-controlled trial took place across 99 primary care centers in the UK. Participants were recruited between March 28, 2019, and January 31, 2020, with 6 months of follow-up. Participants were female, 18 years or older, living in the community, and had evidence in their primary care record of consultations for at least 2 UTIs in the preceding 6 months or 3 UTIs in 12 months. Invitation to participate was made by their primary care center. A total of 7591 participants were approached, 830 responded, and 232 were ineligible or did not proceed to randomization. Statistical analysis was reported in December 2022. Two grams daily of d-mannose powder or matched volume of placebo powder. The primary outcome measure was the proportion of women experiencing at least 1 further episode of clinically suspected UTI for which they contacted ambulatory care within 6 months of study entry. Secondary outcomes included symptom duration, antibiotic use, time to next medically attended UTI, number of suspected UTIs, and UTI-related hospital admissions. Of 598 women eligible (mean [range] age, 58 [18-93] years), 303 were randomized to d-mannose (50.7%) and 295 to placebo (49.3%). Primary outcome data were available for 583 participants (97.5%). The proportion contacting ambulatory care with a clinically suspected UTI was 150 of 294 (51.0%) in the d-mannose group and 161 of 289 (55.7%) in the placebo group (risk difference, -5%; 95% CI, -13% to 3%; P = .26). Estimates were similar in per protocol analyses, imputation analyses, and preplanned subgroups. There were no statistically significant differences in any secondary outcome measures. In this randomized clinical trial, daily d-mannose did not reduce the proportion of women with recurrent UTI in primary care who experienced a subsequent clinically suspected UTI. d-Mannose should not be recommended for prophylaxis in this patient group. isrctn.org Identifier: ISRCTN13283516.

Hospital admission after primary care consultation for community-onset lower urinary tract infection: a cohort study of risks and predictors using linked data.

Urinary tract infections (UTIs) are a common indication for antibiotic prescriptions, reductions in which would reduce antimicrobial resistance (AMR). Risk stratification of patients allows reductions to be made safely. To identify risk factors for hospital admission following UTI, to inform targeted antibiotic stewardship. Retrospective cohort study of East London primary care patients. Hospital admission outcomes following primary care consultation for UTI were analysed using linked data from primary care, secondary care, and microbiology, from 1 April 2012 to 31 March 2017. The outcomes analysed were urinary infection-related hospital admission (UHA) and all-cause hospital admission (AHA) within 30 days of UTI in primary care. Odds ratios between specific variables (demographic characteristics, prior antibiotic exposure, and comorbidities) and the outcomes were predicted using generalised estimating equations, and fitted to a final multivariable model including all variables with a P-value <0.1 on univariable analysis. Of the 169 524 episodes of UTI, UHA occurred in 1336 cases (0.8%, 95% confidence interval [CI] = 0.7 to 0.8) and AHA in 6516 cases (3.8%, 95% CI = 3.8 to 3.9). On multivariable analysis, increased odds of UHA were seen in patients aged 55-74 years (adjusted odds ratio [AOR] 1.49) and ≥75 years (AOR 3.24), relative to adults aged 16-34 years. Increased odds of UHA were also associated with chronic kidney disease (CKD; AOR 1.55), urinary catheters (AOR 2.01), prior antibiotics (AOR 1.38 for ≥3 courses), recurrent UTI (AOR 1.33), faecal incontinence (FI; AOR 1.47), and diabetes mellitus (DM; AOR 1.37). Urinary infection-related hospital admission after primary care consultation for community-onset lower UTI was rare; however, increased odds for UHA were observed for some patient groups. Efforts to reduce antibiotic prescribing for suspected UTI should focus on patients aged <55 years without risk factors for complicated UTI, recurrent UTI, DM, or FI.

The effect of absent or deferred antibiotic treatment on complications of common infections in primary care

ObjectivesThe objective of this study was to compare the incidence rate for complications to upper respiratory tract infections (URTIs), including acute bronchitis and lower urinary tract infections (UTIs), for those treated with antibiotics compared to those who were not. MethodsThis was a population-based retrospective cohort study in Sweden. Patients diagnosed with otitis, pharyngotonsillitis, sinusitis, acute bronchitis, and lower UTI in primary care between 2014 and 2020 were included. Data on prescribed and dispensed antibiotics and comorbidities for each subject were collected. The outcome we investigated was the number of infectious complications within 30 days and if antibiotic treatment had any effect on risk reduction. ResultsThere were 202,995 episodes of otitis, 388,158 pharyngotonsillitis, 125,792 sinusitis, 220,960 bronchitis, and 377,954 lower UTIs in our cohort. No increased risk for complications was seen for untreated compared with treated cases with URTI. For lower UTI, the adjusted odds ratio for febrile UTI or bloodstream infection was 1.53 (95% confidence interval 1.39-1.68). ConclusionThe risk for infectious complications from common URTIs is low and not modified by antibiotic treatment. On the contrary, patients diagnosed with UTI in whom antibiotics were withheld had an increased 30 days risk for severe infections.

Antibiotic consumption and time to recovery from uncomplicated urinary tract infection: secondary analysis of observational data from a point-of-care test trial.

Randomised trials provide high-quality evidence on the effects of prescribing antibiotics for urinary tract infection (UTI) but may not reflect the effects in those who consume antibiotics. Moreover, they mostly compare different antibiotic types or regimens but rarely include a 'no antibiotic' group. To estimate the effect of antibiotic consumption, rather than prescription, on time to recovery in females with uncomplicated UTI. Secondary analysis of 14-day observational data from a point-of-care test trial for UTI in primary care in England, the Netherlands, Spain, and Wales, which ran from 2012 to 2014. Clinicians treated patients using their own judgement, providing immediate, delayed, or no antibiotic. UTI-symptomatic females who either consumed or did not consume antibiotics during a 14-day follow-up were included. Antibiotic consumption was standardised across participants and grouped into either ≤3 or >3 standardised antibiotic days. To account for confounders, a robust propensity score matching analysis was conducted. Adjusted Kaplan-Meier and Cox proportional hazard models were employed to estimate time to recovery and hazard ratios, respectively. A total of n = 333 females who consumed antibiotics and n = 80 females who did not consume antibiotics were identified and included in the study. The adjusted median time to recovery was 2 days longer among patients who did not consume antibiotics (9 days, 95% confidence interval [CI] = 7 to 12) compared with those who did (7 days, 95% CI = 7 to 8). No difference was found between those who consumed ≤3 (7 days, 95% CI = 7 to 8) compared with >3 standardised antibiotic days (7 days, 95% CI = 6 to 9). Consuming antibiotics was associated with a reduction in self-reported time to recovery, but more antibiotics exposure was not associated with faster recovery in this study.

Treating urinary tract infections in public sector primary healthcare facilities in Cape Town, South Africa: A pharmaceutical perspective

&#x0D; &#x0D; &#x0D; &#x0D; Background. Antibiotic resistance is a global healthcare burden complicating the management of infections. Urinary tract infections (UTIs) are commonly treated in primary care. Managing UTIs appropriately in primary care can combat antibiotic resistance. The treatment practices for UTIs in primary care in Western Cape Province, South Africa, are not well described.Objectives. To describe treatment of UTIs in adults in primary care in the Cape Town metropole public sector of the Western Cape. Method. A retrospective multicentre medical records review of patients diagnosed with UTIs was conducted during 1 October 2020 - 28 February 2021. Six public sector primary healthcare facilities were included in the study through random selection from three of the four substructures in the Cape Town metropole. Medical records of adult patients diagnosed with UTIs, through clinical diagnosis or microbiological testing, were identified via a selective sampling process. Data were collected from medical records using a standardised data collection tool.&#x0D; Results. A total of 401 UTI episodes occurred in 383 patients during the study period. The majority of UTI episodes (84.3%) occurred in females, complicated UTIs (74.1%) were more common than uncomplicated UTIs, and nitrofurantoin (57.1%) was frequently prescribed, followed by ciprofloxacin (39.7%). Compliance with urine microscopy recommendations was low (6.7%), and antibiotics were appropriately selected in 75.0% of uncomplicated and 70.0% of complicated UTI episodes.&#x0D; Conclusion. Interventions are required to improve compliance with treatment recommendations as per the standard treatment guidelines, especially when selecting the appropriate antibiotic, duration of therapy and urine microscopy.&#x0D; &#x0D; &#x0D; &#x0D;

Antimicrobial resistance in patients with suspected urinary tract infections in primary care in Assam, India.

ObjectivesWe investigated the prevalence and diversity of antimicrobial resistance in bacteria isolated from urine samples of community-onset urinary tract infection (UTI) patients in southern Assam, India.MethodsFreshly voided midstream urine samples were collected from patients attending primary healthcare centres, with the patients’ epidemiological data also recorded. Species identification was confirmed using a VITEK 2 compact automated system. Phenotypic confirmation of ESBLs was performed using the combined disc diffusion method (CLSI 2017) and carbapenemase production was phenotypically characterized using a modified Hodge test. Common ESBLs and carbapenem-resistance mechanisms were determined in Escherichia coli isolates using PCR assays. Incompatibility typing of the conjugable plasmids was determined by PCR-based replicon typing; the phylotypes and MLSTs were also analysed.ResultsA total of 301 (59.7%) samples showed significant bacteriuria along with symptoms of UTI and among them 103 isolates were identified as E. coli of multiple STs (ST3268, ST3430, ST4671 and others). Among them, 26.2% (27/103) were phenotypically ESBL producers whereas 12.6% (13/103) were carbapenemase producers. This study describes the occurrence of diverse ESBL genes—blaCTX-M-15, blaSHV-148, blaPER-1 and blaTEM—and two E. coli isolates carrying the blaNDM-1 carbapenemase gene. ESBL genes were located within transconjugable plasmids of IncP and IncF type whereas blaNDM-1 was carried in an IncFrepB type plasmid.ConclusionsThis study illustrates the high rate of MDR in E. coli causing UTI in primary care in rural Assam. UTIs caused by ESBL- or MBL-producing bacteria are very difficult to treat and can often lead to treatment failure. Thus, future research should focus on rapid diagnostics to enable targeted treatment options and reduce the treatment failure likely to occur with commonly prescribed antibiotics, which will help to combat antimicrobial resistance and the burden of UTIs.

Diagnosis and Management of UTI in Primary Care Settings-A Qualitative Study to Inform a Diagnostic Quick Reference Tool for Women Under 65 Years.

Background: To inform interventions to improve antimicrobial use in urinary tract infections (UTIs) and contribute to a reduction in Escherichia coli bloodstream infection, we explored factors influencing the diagnosis and management of UTIs in primary care. Design: Semi-structured focus groups informed by the Theoretical Domains Framework. Setting: General practice (GP) surgeries in two English clinical commissioning groups (CCGs), June 2017 to March 2018. Participants: A total of 57 GP staff within 8 focus groups. Results: Staff were very aware of common UTI symptoms and nitrofurantoin as first-line treatment, but some were less aware about when to send a urine culture, second-line and non-antibiotic management, and did not probe for signs and symptoms to specifically exclude vaginal causes or pyelonephritis before prescribing. Many consultations were undertaken over the phone, many by nurse practitioners, and followed established protocols that often included urine dipsticks and receptionists. Patient expectations increased use of urine dipsticks, and immediate and 5 days courses of antibiotics. Management decisions were also influenced by patient co-morbidities. No participants had undertaken recent UTI audits. Patient discussions around antibiotic resistance and back-up antibiotics were uncommon compared to consultations for respiratory infections. Conclusions: Knowledge and skill gaps could be addressed with education and clear, accessible, UTI diagnostic and management guidance and protocols that are also appropriate for phone consultations. Public antibiotic campaigns and patient-facing information should cover UTIs, non-pharmaceutical recommendations for “self-care”, prevention and rationale for 3 days antibiotic courses. Practices should be encouraged to audit UTI management.

Antibiotic management of urinary tract infection in elderly patients in primary care and its association with bloodstream infections and all cause mortality: population based cohort study

ObjectiveTo evaluate the association between antibiotic treatment for urinary tract infection (UTI) and severe adverse outcomes in elderly patients in primary care.DesignRetrospective population based cohort study.SettingClinical Practice Research Datalink (2007-15)...

Stratification by demographic and clinical data of the antibiotic susceptibility of Escherichia coli from urinary tract infections of the community

AimTo determine the patterns of antibiotic susceptibility of Escherichia coli strains isolated from adult patients with urinary tract infection (UTI), and to stratify the results by age and type of UTI to verify if there are statistically significant differences that can help physicians to prescribe better empirical antibiotherapy. DesignCross-sectional prospective study. LocationCommunity of Getafe (Madrid). Primary care level. Participants100 E. coli strains, randomly chosen, isolated from the urine (104–105cfu/ml) of different patients from primary care centers in the Getafe area. Main measurementsThe antibiotic susceptibility of the strains was evaluated and the results were stratified by age and type of UTI. The clinical and demographic data of the patients were analyzed, classifying each episode as complicated UTI or uncomplicated UTI. ResultsStrains isolated from patients with uncomplicated UTI showed significantly greater susceptibility than those of complicated UTI to amoxicillin (65.9% vs. 30.6%, p=0.001), amoxicillin/clavulanic acid (95.5% vs. 77.6%, p=0.013) and ciprofloxacin (81.8% vs. 63.3%, p=0.047). In complicated UTI, susceptibility to ciprofloxacin was significantly greater in the ≤65 years age group compared to the older age group (78.3% vs. 50%, respectively, p=0.041). In the rest of antibiotics, no statistically significant differences were obtained when comparing by age (≤65 years versus >65 years), both in uncomplicated and complicated UTI. ConclusionsClinical and demographic data of patients with UTI are of great importance in the results of the antibiotic susceptibility in E. coli. Antibiograms stratified by patient characteristics may better facilitate empirical antibiotic selection for UTI in primary care.

Antimicrobial resistance in women with urinary tract infection in primary care: No relation with type 2 diabetes mellitus

AimsTo determine if type 2 diabetes mellitus (T2DM) is associated with the spectrum of uropathogens and antimicrobial resistance in urinary tract infections (UTI) in primary care. MethodsA cross-sectional study in female outpatients ≥30 years with positive urine cultures. T2DM patients were 1:1 matched to controls by age group and general practitioner (GP). GPs were sent questionnaires for additional data. Uropathogens and resistance patterns were compared between patients with and without T2DM. Multivariable regression analysis was performed to assess the independent association between T2DM and resistance to first line treatments, defined as resistance to nitrofurantoin, trimethoprim, fosfomycin, ciprofloxacin, amoxicillin/clavulanic acid and/or trimethoprim/sulfamethoxazole. ResultsIn 566 urine cultures, 680 uropathogens were found. Resistance to first line treatment antibiotics was present in 62.5% of patients. Frequencies and resistance rates of uropathogens did not differ between both groups of patients. Previous UTI and previous hospital admission were independent risk factors for resistance, but T2DM was not. ConclusionsIn this study T2DM was not an independent risk factor for antimicrobial resistance in UTI in primary care. Previous UTI and hospitalisation are drivers of resistance and should be included in the decision to perform a urine culture to target first line UTI treatment.

Point of care susceptibility testing in primary care - does it lead to a more appropriate prescription of antibiotics in patients with uncomplicated urinary tract infections? Protocol for a randomized controlled trial.

BackgroundUrinary tract infection (UTI) is a common infection in primary care and is the second leading reason for prescription of antibiotics in Denmark. The diagnosis is often based on symptoms and urine dip-stick, which has limited validity, causing the risk of unnecessary antibiotic prescription. Additionally, with increasing antibiotic resistance, the risk of choosing an antibiotic to which an infecting pathogen is resistant is rising. Combined point-of-care-tests (POCT) for urine culture and susceptibility testing have been developed and validated for primary care, and performing such a test in all patients with suspected UTI in primary care seems rational in order to reduce the use of inappropriate antibiotics. However, the clinical effect of the culture and susceptibility test has not yet been investigated. This study aims to investigate whether POCT urine culture and susceptibility testing decreases the inappropriate use of antibiotics and leads to faster patient recovery.Methods/designRandomized controlled open label trial of two diagnostic approaches. 750 patients with symptoms of uncomplicated UTI, consecutively contacting their general practitioner (GP), randomized to either POCT urine culture and susceptibility testing and targeted treatment or POCT urine culture without susceptibility testing and empirical treatment. Treatment is started when the POCT is read. The two groups are compared with regard to appropriate choice of antibiotics, clinical remission, and microbiological cure rates.DiscussionThe results of this study may provide important evidence to recommend POCT culture and susceptibility testing in all patients with suspected uncomplicated UTI. This could become an additional strategy to fight antibiotic resistance.Trial registrationClinicalTrials.gov NCT02323087.

Point of care testing for urinary tract infection in primary care (POETIC): protocol for a randomised controlled trial of the clinical and cost effectiveness of FLEXICULT™ informed management of uncomplicated UTI in primary care

BackgroundUrinary tract infections (UTI) are the most frequent bacterial infection affecting women and account for about 15% of antibiotics prescribed in primary care. However, some women with a UTI are not prescribed antibiotics or are prescribed the wrong antibiotics, while many women who do not have a microbiologically confirmed UTI are prescribed antibiotics. Inappropriate antibiotic prescribing unnecessarily increases the risk of side effects and the development of antibiotic resistance, and wastes resources.POETIC is a randomised controlled trial of a Point Of Care Test (POCT) (Flexicult™) guided UTI management strategy for use in primary care, which may help General Practitioners more effectively decide both whether or not to prescribe antibiotics, and if so, to select the most appropriate antibiotic.Methods/design614 adult female patients will be recruited from four primary care research networks (Wales, England, Spain, the Netherlands) and individually randomised to either POCT guided care or the guideline-informed ‘standard care’ arm. Urine and stool samples (where possible) will be obtained at presentation (day 1) and two weeks later for microbiological analysis. All participants will be followed up on the course of their illness and their quality of life, using a 2 week self-completed symptom diary. At 3 months, a primary care notes review will be conducted for evidence of further evidence of treatment failures, recurrence, complications, hospitalisations and health service costs.The primary objective is to compare appropriate antibiotic use on day 3 between the POCT and standard care arms using multi-level logistic regression to produce an odds ratio and associated 95% confidence interval. Costs of the two management approaches will be assessed in terms of the primary outcome.DiscussionAlthough the Flexicult™ POCT is used in some countries in routine primary care, it’s clinical and cost effectiveness has never been evaluated in a randomised clinical trial. If shown to be effective, the use of this POCT could benefit individual sufferers and provide evidence for health care authorities to develop evidence based policies to combat the spread and impact of the unprecedented rise of infections caused by antibiotic resistant bacteria in Europe.Trial registration numberISRCTN65200697 (Registered 10 September 2013).

Supporting the improvement and management of prescribing for urinary tract infections (SIMPle): protocol for a cluster randomized trial.

BackgroundThe overuse of antimicrobials is recognized as the main selective pressure driving the emergence and spread of antimicrobial resistance in human bacterial pathogens. Urinary tract infections (UTIs) are among the most common infections presented in primary care and empirical antimicrobial treatment is currently recommended. Previous research has identified that a substantial proportion of Irish general practitioners (GPs) prescribe antimicrobials for UTIs that are not in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The aim of this trial is to design, implement and evaluate the effectiveness of a complex intervention on GP antimicrobial prescribing and adult (18 years of age and over) patients’ antimicrobial consumption when presenting with a suspected UTI.Methods/designThe Supporting the Improvement and Management of Prescribing for urinary tract infections (SIMPle) study is a three-armed intervention with practice-level randomization. Adult patients presenting with suspected UTIs in primary care will be included in the study.The intervention integrates components for both GPs and patients. For GPs the intervention includes interactive workshops, audit and feedback reports and automated electronic prompts summarizing recommended first-line antimicrobial treatment and, for one intervention arm, a recommendation to consider delayed antimicrobial treatment. For patients, multimedia applications and information leaflets are included. Thirty practices will be recruited to the study; laboratory data indicate that 2,038 patients will be prescribed an antimicrobial in the study. The primary outcome is a change in prescribing of first-line antimicrobials for UTIs in accordance with the Guidelines for Antimicrobial Prescribing in Primary Care in Ireland. The study will take place over 15 months with a six-month intervention period. Data will be collected through a remote electronic anonymized data-extraction system, a text-messaging system and GP and patient interviews and surveys. The intervention will be strengthened by the implementation of a social marketing framework and an economic evaluation.Trial registrationThis intervention is registered at ClinicalTrials.gov, ID NCT01913860.

Managing UTI in primary care: should we be sending midstream urine samples?

The decision to prescribe antibiotics is one of the most common treatment decisions faced by frontline primary care clinicians daily, and urinary tract infection (UTI) is one of the most common bacterial infections encountered.1 Although antimicrobial treatment for UTI is accepted in clinical practice, antibiotic resistance in urinary bacteria is increasing,2 with rates cited in the literature of between 20% and 40% to trimethoprim and amoxicillin respectively.3 Bacteria are adept at side-stepping human intervention (for example, antibiotics and vaccines) and are developing resistance to antibiotics faster than the pharmaceutical industry is developing new ones: only two new classes of antibiotics have been developed in the last 30 years.4 These problems highlight the need for high quality evidence to help primary care clinicians optimise the diagnosis and management of UTI. Fortunately, a plethora of high quality, clinically valuable, primary care research papers have been published recently, including four in the BMJ 5–8 and two in this month's BJGP .9,10 One of the BMJ papers reported that a range of management strategies (immediate versus delayed empirical antibiotics versus antibiotics guided by the results of dipstick versus symptom score versus midstream urine culture) achieved similar symptomatic results, while delayed empirical and dipstick-guided prescribing reduced antibiotic consumption.5 The authors concluded that there is ‘no advantage in routinely sending midstream urine [MSU] samples for [culture]’. This makes for an interesting and contrasting background to one of the papers reported in this month's BJGP ,9 which provides evidence in support of sending MSUs for culture. This study by Vellinga et al provides some original and novel evidence for a practice, I suspect, is commonly used in primary care: that of looking for a previous urine culture to guide the treatment of a current, suspected UTI. …

Diagnosis, treatment and management of urinary tract infections in primary care

Urinary tract infection (UTI) is the most common bacterial infection managed in general practice. Following the introduction of extended nurse prescribing, it is now possible for suitably qualified nurses to assess, manage and treat uncomplicated UTIs in primary care without the need for a GP consultation. This article provides a guide to the diagnosis, treatments available and management of UTIs in primary care.

An audit of RCP guidelines on DMSA scanning after urinary tract infection

AIMTo assess the outcome of imaging investigations carried out in children with urinary tract infection (UTI), to compare the investigations with national guidelines, and to assess the impact on management.METHODSRetrospective...

The struggle to diagnose UTI in children under two in primary care.

The incidence of urinary tract infection (UTI) in childhood is highest in infancy and accounts for 5% of febrile infants. Reflux nephropathy following UTI in early childhood is the commonest preventable cause of chronic renal failure. Recent guidelines aim to improve the diagnosis and management of UTI in small children. To assess management of febrile children and UTI in children under 2 years amongst GPs, and to identify some reasons for the difficulties in diagnosing UTI. Questionnaire distributed by periodical journal. Eighty-two GPs responded, of whom 61 (74%) were unaware of the recent Royal College of Physicians guidelines on childhood UTI. Seventy-seven GPs (94%) would find guidelines helpful on when to send a urine sample for culture from a child under 2 years. Only 11 GPs (14%) regularly sent urine from febrile infants and toddlers; 48 GPs (63%) sent urine from only 0-10% of patients; 21 (26%) were unable to collect urine at all from these children. Several difficulties were identified by GPs regarding investigation for UTI in children. These related to practical difficulties in urine collection and culturing, lack of professional awareness of the importance of UTI and concerns about the costs of investigation. GPs frequently do not investigate for UTI in febrile children due to practical difficulties, lack of awareness and financial costs. National guidelines need to be disseminated and implemented effectively to reach target groups. Further scope for research into a simple, cheap method to collect and test urine has been highlighted as a priority to improve early diagnosis of UTI. Management of UTI in primary care can be improved with carefully evaluated strategies and this could lead to a reduction in the prevalence of renal scarring.