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Independents' Day

GP guidance on UTI testing should undergo NICE review, says health minister

GPs could face a change to guidance for testing in recurrent urinary tract infections, after a health minister said NICE should consider evidence suggesting current diagnostic tests miss half of infections.

Nicola Blackwood, parliamentary under-secretary of state for health, told MPs she had asked NICE experts to look at evidence reported by a specialist clinic in north London that claims to have successfully treated many patients plagued by debilitating symptoms of recurrent UTIs – despite being told they do not have an infection.

The move comes after a House of Commons motion put forward by Hornsey & Wood Green MP Catherine West about the inadequacies of current testing regimes, which involve culture of mid-stream urine specimens to identify bacterial infection in people with recurrent symptoms.

However, current laboratory culture methods are thought to miss 50% of infections and patients may not then receive appropriate follow-up.

NICE does not have specific guidelines on UTIs in adults but produced a Quality Standard last year advising that urine culture should be done to guide a change in antibiotic treatment in people who do not initially respond.

Ms West highlighted alternative methods used by Professor James Malone-Lee at his clinic at the Whittington Hospital, where patients with recurrent UTI symptoms are diagnosed on the basis of their symptoms and microscopic analysis of urine, and treated with long-term courses of narrow-spectrum antibiotics.

Ms Blackwood said that NICE had not yet addressed ‘the specific issues relating to detecting UTIs raised by Professor Malone-Lee and his team of researchers’.

She added: ‘The evidence surveillance team at NICE has been asked to take into account any publications emerging from Professor Malone-Lee's work when it next considers the relevant guidance for review.

'I would encourage Professor Malone-Lee, the Cystitis and Overactive Bladder Foundation and the hon. Lady to take this opportunity to ensure that NICE is kept updated with the latest research... as I have no doubt that it will be helpful in improving guidance in this area.'

Ms Blackwood also highlighted that studies are exploring new methods of urine collection to improve diagnostic accuracy and potential alternatives to prophylactic antibiotics.

Dr Jonathan Rees, chair of the Primary Care Urology Society and a GP in Somerset, welcomed the minister’s comments.

Dr Rees told Pulse: ‘I would be delighted to see a review of this often neglected area of medicine. I am aware through my work, both in general practice and in community urology clinics, of the huge numbers of people suffering from recurrent urinary tract infections.

‘Our diagnostic tools are not up to scratch, and we lack strong guidance on the management particularly of recurrent or chronic symptoms (including when to suspect chronic bladder pain syndrome/interstitial cystitis).’

But Dr Rees added that ‘the use of non-antibiotic measures to reduce the impact of recurrent UTI is underemphasised’.

A NICE spokesperson said: 'We conduct regular reviews of our published guidance taking into account any relevant new evidence. Information on Professor Malone-Lee’s work has been received by NICE and has been passed onto our guidance team so it can be taken into account when any relevant guidance is next reviewed.'

Recurrent UTI - what NICE says

NICE has not produced its own specific guideline on UTI in adults, but it produced a quality standard in 2015, which states that 'a urine culture is needed to guide a change in antibiotic treatment in people who do not respond to initial treatment with antibiotics'.[1]

In a separate Clinical Knowledge Summary, NICE also refers to previous Health Protection Agency advice that GPs should send urine for culture from women with recurrent UTI.

[1] NICE QS90 - Urinary tract infections in adults

[2] NICE CKS - UTI (lower) - women



Readers' comments (12)

  • Never trusted MSUs anyway. Wheres the news here?

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  • Perhaps this is something else the Pharmacists could test for and give antibiotics if needed.

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  • You get what you pay for. Don't send too many MSUs we are told at £35 each MSU sent. Don't prescribe and give 3 days antibiotics if needed.

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  • Interestingly, some weeks ago, there was an extremely good exposure on Woman's Hour about this very subject. I listened intently to the Consultant Urologist bemoaning about the thousands of poor women who suffer unnecessarily from chronic UTIs because of the wrong diagnosis & treatment by GPs. I waited & waited & waited frustratingly for the CORRECT diagnosis & treatment - but he NEVER gave it !
    Medical etiquette !!!

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  • would suggest that microbiology are involved as they are constantly advising us not to treat.

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  • If what we r doing isn't good enough? Then what's the good standard

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  • Fair enough - this actually is an area where GPs see a group of virtually 'incurable' female patients who appear to endure considerable pain and disruption to their lives. The wide range of approaches taken by urologists, gynaecologists and the long standing self-help groups seem to only help rarely.

    An authoritative review of treatment options would be very useful - it is what NICE is for.

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  • I am a dentist and a patient of the Professor Malone Lee mentioned in the article. I have suffered chronic UTI for five years and it is life ruining.
    It started in my final year of dental school with an acute UTI. I had a few different courses of antibiotics and the symptoms eventually settled but didn't go away completely. I went back to my GP and asked for more antibiotics. I still had niggling low grade UTI symptoms and knew it hadn't fully gone away. Now my tests were coming back negative or as 'mixed growth of insignificance'. I became more and more unwell. I became fatigued and struggled to attend university. All the while my UTI symptoms remained. I went back to my GP and had bloods, they couldn't find anything wrong with me. I begged them for antibiotics till I was blue in the face. I knew I still had a UTI and it was making me very unwell.
    Eventually I dropped out of dental school. I went to see urologists had all the scans and a cystoscopy, I saw ME specialists. No one could work it out. I was bed bound for a year. Eventually I was referred to Professor Malone Lee at the LUTS clinic at Whittington hospital in London. When I saw him my urine was saturated with white blood cells and epithelial cells. When he said you have a UTI I cried with happiness.
    I have since been on oral antibiotics which control it, for some eradication takes 6 months, for others longer. Because the bacteria were left to live in my urine they learnt to invade the epithelial cells lining the bladder. Inside the cells they replicate hidden from wbc's and antibiotics. When the cell is shed the bacteria infect new cells. Long term antibiotics stop the reinfection of new cells. Eradication can, for some, take a long time. The long term antibiotics have given me my life back. New treatments are being developed.
    Had my GP known that both dipsticks and MSU's are NOT reliable and in fact miss up to 50% of genuine infection maybe she would have given me a longer course of antibiotics in the first place and saved me a lot of misery.
    MSU culture has been discredited in the literature as far back as 1983.
    Partial treatment of UTI because of the reliance on these insensitive tests for diagnosis is causing serious chronic disease in an estimated 0.6% of the population.
    I am part of a patient campaign Chronic Urinary Tract Infection campaign (CUTIC). We aim to raise awareness of the failings of currents testing regimes for UTI and to lobby for better guidelines for diagnosing and treating UTI.

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  • I had no idea msu was so insensitive. Like most tests i suppose. Treat the patient not the numbers.
    Can a lack of haematuria be relied on to rule out bladda cancer in pt with chronic cystitis sumpts. Happy to give longer courses in primary care but they probably need cystosvopy to rule out other xauses including cancer in older patients.

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  • I trained as a medical doctor and along the training had numerous 'minor' UTIs with gross haematuria. I was treated with short course typical antibiotics with my urine cultures either not being done/negative/ or growing 'odd bugs.

    Fast forward several years and I found myself in dire straits with an automimmune condition lupus. Despite steroids, IVIG and warfarin I did not improve. I developed constant agonising kidney pain which I thought was 'serositis'. All my MSUs were generally negative.

    I eventually developed multi-drug resistant pyelonephritis which left me in a state of recurrent sepsis /severe sepsis, meaning I was in hospital for 16 months. Even then my MSUs were not reliable and I endured many agonising weeks without treatment 'waiting for the results to show what we are treating!'. (eventually 'proving' I had pseudomonas, VRE, citrobacter, proteus, E.Coli)

    Eventually it was so bad, I literally was at home for a week or two before once again I became septic (Temp 38-39, tachycardic, hypotensive, with a raised lactate). The constant infections affected my kidney function and it deteriorated to a GFR of 50 ish (in my mid-late 30s)

    The tertiary referral hospital microbiology where I was a long term inpatient said they no longer knew how to deal with me. I was scared, I thought i was going to die of these UTIs.

    In fact, fate intervened and i was referred to Professor Malone-Lee, an unusual breed a 'medical urologist.

    His hypothesis is that bacteria are intracellular and within the bladder and entire urinary tract epithelium. This means that as the layers gradually shred - the bacteria slough off and constantly 're-infect' the urinary tract. However, this is NOT a new infection - it is the same one just constantly breaking free of the epithelium.

    Professor Malone Lee's work is a breakthrough - he has discovered that MSUs are correctt less than 50% of the time. This is key. Patients like myself, who had numerous infections as a young woman, and then numerous antibiotics were left open to developing a more deep-seated infection. I now have it in my right kidney. Professor Malone Lee however, believes the way to treat these embedded infections is through long term simple antibiotics.

    Remember - I was in a repeatedly critical situation with recurrent severe sepsis and being given IV meropenem, IV tazocin, IV linezolid, IV chloramphenicol, IV amoxicillin and IV daptomycin. I even got to the point where I was prescribed the 'reserve' antibiotics of IV colistin.

    Imagine my relief and hope when I finally met Professor Malone Lee who told me of his hypothesis and weaned me off the big guns of the antibiotic world and onto first generation oral antibiotics. I've now been on his treatment for 2.5 years and I've not been admitted to hospital once for pyelonephritis. Not once!!

    My mainstay is nitrofurantoin - critically at treatment dose NOT prophylactic dose (which, by the way achieved nothing just more sepsis).

    I can finally lead a life. UTIs can be life-threatening. They are not necessarily minor. They can also cause much distress and a severe reduction in quality of life. This issue deserves the urgent attention of all physicians.

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