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A faulty production line

GP expert calls for women to get antibiotics for cystitis without prescription

Allowing women with uncomplicated cystitis to ‘bypass’ their GP and obtain antibiotics directly from a pharmacy without a prescription would save three million GP appointments a year, a GP expert has claimed.  

The piece in the BMJ – written by Dr Kyle Knox from the Nuffield Department of Health Sciences, University of Oxford – argues that acute uncomplicated urinary tract infections (AUUTIs) such as cystitis are the most common bacterial infections in women, and that a short course of the antibiotic nitrofurantoin sees symptoms usually start to improve after a day or two.

He said that at a time of ‘overstretched primary care services’, patients should be able to access safe treatment without seeing a clinician.

However, the RCGP said there were dangers in allowing patients to sidestep GPs.

Cystitis affects around half of women at least once in their lifetime and is the reason behind 1% of the 300 million GP consultations held annually in the UK.

Dr Knox says: ‘In an era of ready access to information, increasing patient autonomy and overstretched primary care services, it would seem a good idea for women to be able to access safe and effective treatment without the costs and delays associated with consulting a clinician to obtain a prescription.’

However, despite clear guidance, characteristic clinical syndrome, and predictable efficacy and safety, nitrofurantoin remains a prescription-only drug.

The current prescription-only approach does nothing to limit antimicrobial use but creates urgent demand in primary care – and an additional hurdle for women to access safe and effective treatment, he argues.

He points out that the availability of pregnancy tests, emergency contraception and antimalarial prophylaxis is commonplace in UK pharmacies while some antibiotics are already available from pharmacies without prescription in the UK.

‘A change in the regulations that govern access to nitrofurantoin would be worthwhile only if it was taken up by women seeking treatment,’ he writes.

But RCGP chair Dr Maureen Baker said: ‘There is the risk that bypassing the GP for patients with cystitis might lead to recurrent strains of the infection being treated inappropriately, and more serious conditions going undetected.’

She also argued that greater effort should be made to identify new non-antibiotic strategies and make alternative treatments to cystitis more widely available in a bid to reduce the need for and resistance to the drugs, so that they will still be effective when patients really need them.

Readers' comments (10)

  • Vinci Ho

    The only concern here is actually coming from latest NICE guidance on bladder cancer:
    1.6.5 Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection. [new 2015]

    So you have to stop 60 and over to obtain nitrofurantoin over the counter??

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  • I agree withe bmj, anything patient centred or encourages self management the rcgp is usually against.

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  • There were a number of PGD's in pharmacy providing Trimethoprim for cystitis and these were stopped on the request of the Dept of Health.

    Personally, I think that it is pretty easy to put in safeguards that will allow people with recurrent/complicated UTI's to not be treated in pharmacy, however, uncomplicated UTI is a different matter.
    This may free up some time for GP's to see the complicated ones more quickly and prevent further problems.

    I agree with Maureen Baker in principal...however, what alternative strategies and treatments does she mean?

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  • How long before nitrofurantoin will be as useless as trimethoprim due to overuse, leading to antibiotics resistance ?

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  • Yes, what exactly does Dr Baker mean? I wonder if she is thinking of Mist Pot Cit? Helps Sx only. (sometimes!) Let's use less antibiotics and watch cases of sepsis rise. (I know, it won't be often but devastating when it does) Also CRF from scarred, chronically infected kidneys.

    DOI- Mrs gets a lot of UTIs and has had negative Investigations- finds Nitro works in hours usually and is very grateful that her GP lets her keep a stock in house and on rept.

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  • I think this is an excellent idea, and it wouldn't be difficult for pharmacists to follow a procedure that would direct people with recurrent UTIs or other symptoms that might suggest something other than simple cystitis to their GP.

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  • sensible idea -there is various research supporting provision of antibiotics without face to face gp consultation--if GPS can do after phone consultations why not pharmacists face to face

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  • Dear All,
    We have a protocol and our receptionists and HCA do it all.
    No cock ups, patients happy, AB prescribing lowest in the CCG, no wasted appointments.
    Paul C

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  • And don't forget you can easily purchase trimethoprim on line as many women do already. There seems to be a large group of employed financially buoyant patients who are semi-private already and purchase medication from mostly UK online pharmacies. This area is just crying out for some research.

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  • Are we all pretending here that recurrent UTI is something that we as GPs can get appropriate microbial diagnostic tests. As a GPwSI in this area I see many recurrent UTI patients who never get positive culture results, crippling GPs ability to manage appropriately. Urologists are not interested. These poor patients are left with life altering symptoms. Surely we need to address this "burning: issue first.

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