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Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial
Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial
Objective: To assess the impact of different management strategies in urinary tract infections.

Design: Randomised controlled trial.

Setting: Primary care

Participants: 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

Intervention: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

Main outcome measures: Symptom severity (days 2 to 4) and duration, and use of antibiotics.

Results: Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177).

There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001).

Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

Conclusion: All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

Study registration: National Research Register N0484094184 ISRCTN: 03525333
0959-8138
c199
Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Moore, M.V.
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Turner, S.
42f19397-8e9f-435d-a348-2cc1639b5eb4
Rumsby, K.
2002ee8a-32ac-4119-869d-ed35164c3b51
Warner, G.
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Lowes, J.A.
eff6751b-62b6-4755-a92e-b1c6e03db3b6
Smith, H.
cc42a332-71ec-436f-8207-9151275a92d8
Hawke, C.
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Arscott, A.
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Turner, D.
dbe8594a-d211-4efe-abec-46a6e0451623
Mullee, M.
fd3f91c3-5e95-4f56-8d73-260824eeb362
Little, P.
1bf2d1f7-200c-47a5-ab16-fe5a8756a777
Moore, M.V.
1be81dad-7120-45f0-bbed-f3b0cc0cfe99
Turner, S.
42f19397-8e9f-435d-a348-2cc1639b5eb4
Rumsby, K.
2002ee8a-32ac-4119-869d-ed35164c3b51
Warner, G.
a7c8d450-67a4-46c9-ad1e-4a17d6816590
Lowes, J.A.
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Smith, H.
cc42a332-71ec-436f-8207-9151275a92d8
Hawke, C.
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Arscott, A.
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Turner, D.
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Mullee, M.
fd3f91c3-5e95-4f56-8d73-260824eeb362

Little, P., Moore, M.V., Turner, S., Rumsby, K., Warner, G., Lowes, J.A., Smith, H., Hawke, C., Arscott, A., Turner, D. and Mullee, M. (2010) Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. BMJ, 340, c199. (doi:10.1136/bmj.c199). (PMID:20139214)

Record type: Article

Abstract

Objective: To assess the impact of different management strategies in urinary tract infections.

Design: Randomised controlled trial.

Setting: Primary care

Participants: 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

Intervention: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

Main outcome measures: Symptom severity (days 2 to 4) and duration, and use of antibiotics.

Results: Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177).

There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001).

Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

Conclusion: All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

Study registration: National Research Register N0484094184 ISRCTN: 03525333

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More information

Published date: 5 February 2010
Organisations: Community Clinical Sciences

Identifiers

Local EPrints ID: 143631
URI: http://eprints.soton.ac.uk/id/eprint/143631
ISSN: 0959-8138
PURE UUID: 327a2d60-dce3-4543-93e8-f7ec7edea25c
ORCID for M.V. Moore: ORCID iD orcid.org/0000-0002-5127-4509
ORCID for K. Rumsby: ORCID iD orcid.org/0000-0002-8573-3718
ORCID for C. Hawke: ORCID iD orcid.org/0000-0001-5986-3300

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Date deposited: 12 Apr 2010 13:54
Last modified: 10 Jan 2022 02:50

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Contributors

Author: P. Little
Author: M.V. Moore ORCID iD
Author: S. Turner
Author: K. Rumsby ORCID iD
Author: G. Warner
Author: J.A. Lowes
Author: H. Smith
Author: C. Hawke ORCID iD
Author: A. Arscott
Author: D. Turner
Author: M. Mullee

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