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

Little, P, Moore, M V, Turner, S, Rumby, K, Warner, G, Lowes, J A, Smith, Helen, Hawke, C, Leydon, G, Arscott, A, Turner, D and Mullee, M (2010) Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial. British Medical Journal, 340. ISSN 0959-8138

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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.

Item Type: Article
Keywords: Infectious diseases, Urological surgery, Urology, Clinical trials (epidemiology), Quantitative research, General practice / family medicine, Immunology (including allergy)
Schools and Departments: Brighton and Sussex Medical School > Primary Care and Public Health
Subjects: R Medicine > R Medicine (General)
Depositing User: Jessica Stockdale
Date Deposited: 13 Jul 2012 09:29
Last Modified: 06 Mar 2017 20:57
URI: http://srodev.sussex.ac.uk/id/eprint/40094

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