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'Optimise antibiotic prescribing for UTIs,' NICE urges GPs

GPs are being urged to ‘optimise’ their use of antibiotics for treating UTIs in new draft guidance from NICE on treating UTIs.

GPs are being advised to counsel patients on effective self-care and to consider delayed prescriptions for UTIs in an effort to reduce the risk of antibiotic resistance.

The draft guidance for treating lower urinary tract infections, which is out for consultation until early June, recommends that all patients are given advice about self-care, including taking paracetamol, ensuring adequate fluid intake and explaining that there is no evidence for the use of cranberry products in treating UTI.

NICE suggests that GPs should consider waiting for microbiological results before deciding which antibiotic to prescribe, depending on the severity of the patient’s symptoms.

The guidance also recommends taking in to account the severity of symptoms, the level of risk and whether the patients has previously used antibiotics that may have led to resistance before prescribing.

NICE have also released draft guidance for acute pyelonephritis, recurrent UTI and catheter-associated UTI, which are also out for consultation.

The pyelonephritis and catheter-associated UTI guidance recommends reviewing the choice of antibiotic when urine cultures become available and changing the prescription if necessary based on the results.

Professor Mark Baker, director for the centre of guidelines at NICE, said: ‘We recognise that the majority of UTIs will require antibiotic treatment, but we need to be smarter with our use of these medicines.

‘Our new guidance will help healthcare professionals to optimise their use of antibiotics. This will help to protect these vital medicines and ensure that no one experiences side effects from a treatment they do not need.’

Dr Susan Hopkins, deputy director for antimicorbial resistance and healthcare associated infections at Public Health England, said: ‘Our surveillance shows that more than a third of laboratory confirmed E.coli UTIs display resistance to key antibiotics.

'We are therefore urging GP practices and hospitals to follow the new guidelines so they can prescribe antibiotics appropriately to their patients. This will preserve our antibiotics so that they not only save lives today but can continue to save lives tomorrow.’

The guidance comes as Public Health England announced its ambition in February to cut GP prescribing over the next two years after research found that ‘at least’ 20% of GP antibiotic prescriptions in England were inappropriate. 

Guideline in full

Lower urinary tract infections

Give advice about managing symptoms with self-care (see the recommendations on self-care) to all people with lower UTI.

Consider a back-up antibiotic prescription or an immediate antibiotic prescription for women with lower UTI who are not pregnant. Take account of:

  • The severity of symptoms.
  • The risk of developing complications.
  • Previous urine culture and susceptibility results.
  • Previous antibiotic use which may have led to resistant bacteria.
  • Preferences of the woman for antibiotic use.

Taking account of the severity of symptoms, consider waiting until any microbiological results are available before prescribing an antibiotic for a woman with lower UTI who is not pregnant.

If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given:

  • Review the choice of antibiotic when microbiological results are available, and
  • Change the antibiotic according to susceptibility results if bacteria are resistant and symptoms are not already improving, using a narrow spectrum antibiotic wherever possible.

When a back-up antibiotic prescription is given, as well as the general advice on self-care, give advice about:

  • An antibiotic not being needed immediately.
  • Using the back-up prescription if symptoms do not start to improve within 48 hours or if they worsen rapidly or significantly at any time.

Catheter-associated UTI

Offer an antibiotic to people with catheter-associated UTI. Take account of:

  • The severity of symptoms.
  • The risk of developing complications.
  • Previous urine culture and susceptibility results.
  • Previous antibiotic use which may have led to resistant bacteria.

When urine culture and susceptibility results are available:

  • Review the choice of antibiotic, and
  • Change the antibiotic according to susceptibility results if the bacteria are resistant and symptoms are not already improving, using narrow spectrum antibiotics wherever possible.

Pyelonephritis

In people aged 16 years and over with acute pyelonephritis obtain a midstream urine sample before prescribing antibiotics and send for culture and susceptibility testing.

When results of urine cultures are available:

  • Review the choice of antibiotic, and
  • Change the antibiotic according to susceptibility results if the bacteria are resistant, using narrow spectrum antibiotics wherever possible.

Source: NICE

Readers' comments (11)

  • 'NICE repeatedly urges granny to suck eggs' (but doesn't demonstrate as it has an egg-allergy itself).

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  • Very clever. Advise withholding antibiotics whilst throwing in enough caveats to condemn any GP naive enough to actually do so. An uncomplicated dipstick positive UTI on Friday may be a pyelonephritis by Saturday and sepsis on Sunday. Try telling the GMC you were waiting for an MSU result Monday whilst they consider whether to refer you for a manslaughter charge.
    By all means issue a deferred prescription, but don’t play Russian roulette with your career by issuing no prescription.

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  • Similar Dr B,with poor ooh provision, an overloaded hospital and A&E, more likely to prescribe on a Friday for borderline UTIs,afterall it is the frontline staff whose head is on the block not the ivory towered ,educational and political committee jockeys.

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  • Idealistic thinking from increasingly out of touch organisation. The "GP expert" will certainly criticise you for not prescribing. The case will probably be dismissed but will take at least 3 years.

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  • NICE are a complete bunch of moon units.
    Until NICE can somehow back this up with concrete medicolegal protection then best advice is just to shut up.

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  • Not treating cystitis is risky enough but waiting for an MSU in a case of acute pyelonephritis? Madness! My MDU fees are high enough thank you!

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  • Publishing guidelines for the sake of guidelines. No thanks. We do not want to be the next Dr Bawa Garba charged with gross negligence manslaughter for not treating an "obvious UTI" or "delayed treatment" causing complications or sepsis. You will now see an era of defensive medicine since that is the standard the GMC, courts/lawyers expect and we can kiss all the NHS savings for investigations, referrals and prescribing goodbye.

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  • UTI causing bacteria can double every 20-minutes.

    To delay treating a clinically apparent UTI seems contrary to both the SIGN guidelines and common sense. Everything we know about sepsis tells us that early treatment of infection is key. Furthermore, standard urine cultures are often so unreliable, it seems illogical to delay treatment waiting for one.

    This latest advice from NICE strikes me as bizarre and inconsistent with most other advice....

    A Ali
    Consultant Urologist

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  • I have been researching this for 37 years and I have a good and strong scientific team. We have been unable to find any better method of diagnosis than clinical skill and experience applied to the history and examination. Immediately fresh urine microscopy to count the white cells remains the best surrogate marker of UTI still after 90 years of use. We and others have published data that show the appalling insensitivity of the dipsticks and the fact that the urine culture cannot distinguish the patients from normal controls.

    In obedience to a health minister I have passed these data to NICE. They wrote back to say the guidelines were all the fault of the Scots. I think that they were bluffing, banking on our recall of what happened to the IXth Hispanic Legion.

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  • Rogue1

    Oh that's where I'm going wrong. I just have a jar of antibiotics and get patients to help themselves.

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