Can we target antibiotics better for urine infections?

By Dr. Oliver van Hecke, NIHR Clinical Lecturer & GP

As GPs at the coalface in the NHS, we have to make decisions about antibiotic treatment,  sometimes, without definitely knowing whether antibiotics are needed, or which antibiotic is the best to use. This is particularly the case for when patients come to the surgery with symptoms suggestive of a urinary tract infection (UTI) – commonly known as a bladder infection.

GPs and nurses prescribe around 75% of all antibiotics used in the NHS. Up to 15% of these antibiotic prescriptions are for ‘simple’ (uncomplicated) UTIs. So, for an average GP surgery of 10,000 patients, this translates to about 156 episodes per year in one surgery. Typically, when a patient comes to the surgery with suspected UTI symptoms (e.g. pain when passing urine), the GP or nurse treats this presumed infection empirically – based on a set number of patient-reported UTI symptoms and may prescribe an antibiotic based on current guidelines.

However, as in life, the situation is far more complex. We know that many of these episodes do not benefit from antibiotics as some symptoms stem from unrelated non-bacterial bladder and urethral irritation. We also know that some UTIs are caused by bacteria resistant to conventional empirical antibiotics from the outset.

Getting the diagnosis right is important because 7 out of 10 UTIs are caused by specific bacteria called Escherichia coli (E .coli). These common bacteria are listed on the World Health Organization’s global priority list of antibiotic-resistant bacteria because, in a very small number of patients (annual incidence 74/100,000 patients), these bacteria enter the bloodstream and may lead to sepsis and death.

Given this complexity, there are tests available at the GP surgery to help guide health professionals. However, currently these tests either require waiting several days to receive results (laboratory-based urine culture) or provide results with sub-optimal diagnostic accuracy (urine dipsticks). This is frustrating for both patients and health professionals because there is either a delay in treatment, inappropriate treatment or a missed diagnosis.

Most GPs will be able to recall that one patient in their surgery, who ended up with awful changes to their quality of life following complications of a UTI. I have a particular patient who, to this day, is so worried that their symptoms might recur, that any bladder niggle or soreness prompts them to (understandably) phone the surgery.

I want to help my patients, but I also know that simply carpet-bombing patients with antibiotics does not help them in the long run. So, is there another way to ensure that patients receive the correct treatment in a timely manner?

In an era of antibiotic-resistant infections, it is critical that patients receive the right antibiotic at the right time with the least harm to present and future patients. This is what we call “antibiotic stewardship” in a nutshell. Under this umbrella of antibiotic stewardship are a number of strategies that we should be using to improve the quality of antibiotic treatment for patients with uncomplicated UTIs.

One of these strategies is the use of rapid diagnostic or point-of-care tests for a suspected UTI. By point-of care, we mean a test (using a urine sample) that is performed at the surgery and provides the GP or nurse with a result within several minutes that will help them make a better decision about whether to prescribe an antibiotic or not and which antibiotic to prescribe.

Encouraged by the prospect of winning the multi-million pound Longitude Prize, innovators worldwide are tantalisingly close to realising affordable diagnostics that produce rapid results within 30 minutes, with more than half of the teams in the running for the prize focused on tackling UTIs. Most importantly these tests will be significantly more accurate than the dipstick, even specifying the correct antibiotic to prescribe to target a patient’s specific infection.

The decision to use an antibiotic is an important one and one that you want to get right.

We need to bring better evidence about using rapid diagnostic tests in general practice so that GPs and nurses can improve how and when we treat even the most ‘straightforward’ UTI. For my patients, I want to see more investment, from both public and private enterprises, focused on developing and evaluating fit-for-purpose diagnostic tests that can be effectively integrated into the GP surgery to better target antibiotics for UTIs.

Dr. Oliver van Hecke chaired a one-day symposium, hosted by the Longitude Prize and The Royal College of Nursing, on UTIs and the clinical need in the UK on 24 February 2020. 

Dr van Hecke is an academic GP at the University of Oxford. He shares his time between Oxford and his clinical practice in Tower Hamlets, London. His research interests are in antibiotic resistance and its impact for primary care,  and developing novel antibiotic stewardship initiatives in the community. Through his research, he has been an advocate for primary care clinicians as a panel witness in the House of Commons, as part of an All-Party Parliamentary Group. He sits on council of the British Society of Antimicrobial Chemotherapy, which is a leading charity dedicated to ensuring the availability and effective use of antimicrobial therapies. Dr van Hecke is an active member of the NIHR Community Healthcare MIC (MedTech and In-vitro diagnostics Co-operative) based in Oxford, which helps to promote and evaluate rapid diagnostic tests in primary care, and he also co-ordinates the Infections Research Group there.