Cystitis, antibiotics and other cures...#Antibioticsawarenessweek

Tim Nedas offers some thoughts and questions to think about as we highlight #AntibioticAwarenessWeek

It is world antibiotics awareness week and a timely occasion for the British Medical Journal to publish a double blind randomised controlled trial (a clinical trial where neither the doctors or patients know what treatment the patient is getting) looking at non-steroidal anti-inflammatories (NSAIDS) compared to antibiotics for uncomplicated UTI' s in women (Kronenberg et al BMJ 2017; 359:j4784).  The headline news from this paper is that although numbers were small (around 120 people in each of the antibiotics or NSAID groups) the antibiotics did a better job with an 80% success rate at three days compared to 54% with NSAID medication.

On the other hand 56% of patients were better on day 3 without antibiotics and giving antibiotics led to a 37% decreased use of antibiotics overall. That is astonishing - half of patients can avoid antibiotics and get better. Perhaps the mantra of wait and see is a worthwhile exercise.

Discussing the trial with another Urology Partner, Richard Hindley, his initial response was "I suspect many who might get through an initial episode with anti-inflammatory drugs may end up representing a few weeks later".  This was a very insightful comment, there was a higher risk of later pyelonephritis (kidney infection) in the NSAID group but despite this the overall use of antibiotics was down 37% in the NSAID group.

The question doctors and patients all have to ask ourselves is;

“Are we prepared to be more resilient in the face of increased risk versus a two thirds chance of avoiding antibiotics?"

Thereby reducing their risk and preserving their benefits for the population as a whole.

These patients were recruited by general practitioners in Switzerland and the patients I see as a urologist are a little different. Almost by definition those patients who see a urologist are not suffering from an uncomplicated UTI. Either having had multiple uncomplicated UTI's, multiple episodes of cystitis symptoms (without proven infection) or a complex UTI (fevers, hospital admission etc).

One of the issues with generic workstreams in primary care is that a patient may end up seeing or at least speaking to several different doctors who all may end up prescribing antibiotics before the hamster wheel of symptoms, antibiotics, symptoms repeat is interrupted. The general guidance is that an uncomplicated UTI may be treated with three days of empirical (best guess) antibiotics without a urine culture or further investigation. The patient can oscillate between a GP practice, A&E department and Out of Hours service very easily before getting the specialist help they may require having had several episodes of symptoms.

When I see a lady who has been referred as suffering recurrent UTI's I have to breach the chasm of distrust that emanates from me trying to establish whether they have truly had infections or not. I hope the patient quickly begins to understand that I have every sympathy with their symptoms but establishing whether they have infective (bacterial) or non-infective (abacterial) cystitis is vital to providing the correct treatment.

It is not clear form the study I have referenced to in this short blog whether all the patients turned out to have culture proven infections but it is probably safe to assume so. 

Before I conclude I must say that there are a great deal of patients who I see who have recurrent symptoms that they manage without antibiotics (increased fluid intake, cystitis powders and rest being key patient-led measures) but who are understandably at their wits end from the frequency and number of episodes. 

To finish let us just reflect on the key statement -  

"There is a greater than 50% chance of getting better without antibiotics."

These wonderful drugs are being misused, in the generally fit and well patient with the truly uncomplicated UTI let us hold fire and give the immune system a chance.

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