Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c199 (Published 05 February 2010) Cite this as: BMJ 2010;340:c199
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Little and colleagues showed clearly that empirical antibiotic
prescription (delayed or immediate) in patients with uncomplicated urinary
tract infections (UUTI) was effective and safe, comparable to an approach
with preceding urine diagnostics.1 This letter describes a further
alternative used at the Swiss Centre for Telemedicine MEDGATE in Basel,
Switzerland. An evidence-based protocol was implemented to manage patients
calling with UUTI. Teleconsultations are done by medical doctors and, when
indicated, antibiotics are prescribed.2
According to this protocol, women between 18 and 65 years with
obvious symptoms of a UUTI present for less than 7 days and without
relevant comorbidity are eligible for telemedical management including
teleprescription of antibiotics. Persons presenting alarm symptoms such as
chills, flank pain, or with recent antibiotic therapy are directly
referred to a face-to-face consultation. First line antibiotic is
trimethoprim/ sulfamethoxazole (160/800 mg, 2x/d for 3 days), second line
antibiotics are norfloxacine (400mg, 2x/d for 3 days) or ciprofloxacine
(250 mg, 2/d for 3 days).2 After three days all patients have a follow-up
teleconsultation to check the clinical evolution and possible side
effects.
We evaluated the safety and effectiveness of managing patients in
this way based on a case series of 499 UUTI women (mean age 38.2 ± 12.6
years) treated between November 1, 2008 and October 31, 2009. Three days
after teleconsultation, the large majority of patients reported complete
relief (78%) or a reduction (14%) in UUTI symptoms. 4% of patients
reported alarm symptoms for pyelonephritis, and 5% observed side effects
they correlated with the prescribed UUTI antibiotic. Overall, in 11% of
women referral to another health care provider for additional diagnostic
or therapeutic interventions was needed (Table 1, sent as an email
attachment).
These data indicate clearly that the safety and effectiveness of
telemedical management in UUTI is similar to that in face-to-face
consultations.3 The basic condition to insure safety is the strict
adherence to the triage protocol and the follow-up call. Telemedical
management of UUTI would have qualified as another alternative to those
studied by Little et al.1 Despite the absence of good-quality head-to-head
comparisons of telemedical versus face-to-face care, authors of current
clinical practice guidelines have started to recommend telemedicine for
UUTI management.4 Telemedical management has the potential to avoid delay
and costs of face-to-face consultations when providing the same safety and
effectiveness.
References
1 Little P, Moore MV, Turner S, Rumsby K, Lowes JA, Smith H, et al.
Effectiveness of five different approaches in management of urinary tract
infection: randomised controlled trial. BMJ 2010;340:c199.
2 Fihn SD. Clinical practice. Acute uncomplicated urinary tract
infection in women. N Engl J Med 2003;349:259-66.
3 McNulty CA, Richards J, Livermore DM, Little P, Charlett A, Freeman
E, et al. Clinical relevance of laboratory-reported antibiotic resistance
in acute uncomplicated urinary tract infection in primary care. J
Antimicrob Chemother 2006;58:1000-8.
4 Schmiemann G, Gebhardt K, Matejczyk M, Hummers-Pradier E. Guideline
for Dysuria of the German College of General Practitioners and Family
Physicians (DEGAM) 2009. http://www.degam.de/typo/index.php?id=73
Competing interests:
The authors are employed by the Swiss Centre for Telemedicine MEDGATE.
Competing interests: No competing interests
Implications of not sending urine specimens in secondary care
The series of papers and the editorial comment on managing urinary
tract infection (BMJ 20th February 2010) warrant a urological comment as
patients with recurrent proven urinary tract sepsis account for a
significant workload.
The requirement for routine urine cultures may not be that relevant
to the individual patient or general practitioner GP), however it will
undoubtedly be of relevance to the sub-group of patients who suffer severe
complicated urinary tract infections requiring hospital admission or
progress to relapsing UTIs where previous bacteriology is crucial to
management.
It is important in primary and secondary care to distinguish between
recurrent infections, which are due to either re-infection or bacterial
persistence, i.e., by the same bacteria from a focus within the urinary
tract, and unresolved infections which are due to inadequate therapy.
Recurrent infection due to bacterial persistence and unresolved infections
are less likely to respond to empirical antibiotics and therefore more
likely to become complicated and require appropriate antibiotics
established from the results of the MSU.
Although the specificity of nitrite dipsticks is high, the
sensitivity of the nitrite dipstick for detecting bacteriuria is in the
range of 35-85%). Therefore a urine dipstick may miss an infection which
an MSU would identify.
The Editorial also raises an important point; that is the proportion
of symptomatic women with no identifiable bacteriological infection at
36%. Lower urinary tract symptoms in women are not always due to bacterial
infection and once the patient has been told that she has infection, it
can be difficult to convince her that her symptoms lie with another
pathology.
Competing interests:
None declared
Competing interests: No competing interests