Test urine before prescribing antibiotics for most UTIs, says NICE
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2076 (Published 10 May 2018) Cite this as: BMJ 2018;361:k2076![Loading Loading](https://cdn.statically.io/img/www.bmj.com/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif)
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We have read the article of Susan Mayor and the NICE guideline on antimicrobial prescribing on lower urinary tract infection with interest (1). We have a number of practical observations to make which we hope would be of help.
There is no indication on antimicrobial allergy as this should be included in the guideline.
Advice should be made to seek for past history of alert organisms such as Meticillin-Resistant Staphylococcus aureus (MRSA),Extended Spetcrum Beta-lactamase (ESBL) producing organisms,Glycopeptide Restistant Enterococci (GRE),Carbapenem Producing Enterobacteriacea (CPE) and Clostridium difficile not only from the urine but also from other sites as this would influence the antimicrobial management of patients with such infections in addition to ensuring good infection prevention and control practice.
There is the challenging issue of ensuring that the antimicrobial therapy is reviewed and acted upon following availability of culture and antimicrobial susceptibility results. In current practice, it is frequently the case that when the culture result is available in terms of identification of the infective agent and its antimicrobial sensitivity profile that for one reason or another that the result is not seen and acted upon. This frequently is encountered in the community setting but may also occur in the hospital setting particularly when a patient is discharged. In these cases the results are often not reviewed and acted upon. It is therefore, recommended when possible that patients are actively involved in their management and are advised to expect and actively enquire about their urine culture results. This will have the desirable outcome in complying with the antimicrobial stewardship programme.
The guidance advises that the antimicrobial agent should be changed when the organism is resistant to it in addition to lack of symptomatic improvement. We wish to assert that antimicrobial therapy should be changed in the presence of antimicrobial resistance even if the patient has symptomatically improved, as there is the potential risk of relapse.
There is no indication of the use and benefit of dipstick testing except in the section of the management of children. The current practice is that it is a routinely used point of care test whereby only positive dipstick samples are sent to the Microbiology Laboratory for culture and sensitivity.
As regards the antimicrobial treatment table section, Nitrofurantoin is mentioned as possible second line presumably when Trimethoprim was used as first line treatment; however Trimethoprim needs to be mentioned as second line when Nitrofurantoin is used as first line therapy.
Finally, Pivmecillinam and Fosfomycin are equally recommended as second line therapy. We wish to make the point that Fosfomycin should be recommended as third line therapy in order to salvage it in the treatment of multi-drug resistant infections such those due to carbapenem-resistant organisms. The increase use of Fosfomycin will inevitably lead to increase resistance to it by a wide range of Gram-negative bacteria mainly those belonging to the Enterobacteriacea family (2).
1. National Institute for Health and Care Excellence. Urinary tract infection (lower): antimicrobial prescribing—NICE guideline (draft for consultation). May 2018. https://www.nice.org.uk/guidance/GID-APG10004/documents/draft-guideline-2
2. Al-Wali W, Hughes C. Fosfomycin should not be first line treatment for uncomplicated urinary tract infection. BMJ2016;352:i413.
Competing interests: No competing interests
Re: Test urine before prescribing antibiotics for most UTIs, says NICE. But collect the specimen properly, store it properly . and test it properly.
Of course you should test the urine.
1. But do the receptionists know WHAT to tell the patient about collecting the specimen?
The rationale of the MSSU is to clear the urethra of extraneous bacteria - contaminants. It follows that the receceptionist should assess the ability of the patient to follow the instructions.
Secondly, the receptionists SHOULD be taught that the procedure of depositing the urine straight into the specimen bottle (which has a diameter seldom exceeding 2 cm) is impossible for an adult male. Therefore the patient should be told to void the mid-stream specimen in a largish container and then transfer it to the specimen bottle.
2. You have received the specimen in the surgery. Have you the ability to store the specimen in a fridge and then transport it to the laboratory?
3. If your logistics are uncertain (shortage of money), and the patient has the ability to take or to send the specimen to the laboratory, please request him to do it.
4. And when you receive the lab report, please, please SEND a message to the patient. Then the patient can collect the prescription, if required. And if the lab report is negative, do please discuss with the patient what should be done next.
Competing interests: No competing interests