Managing UTI in primary care: should we be sending midstream urine samples?

The decision to prescribe antibiotics is one of the most common treatment decisions faced by frontline primary care clinicians daily, and urinary tract infection (UTI) is one of the most common bacterial infections encountered.1 Although antimicrobial treatment for UTI is accepted in clinical practice, antibiotic resistance in urinary bacteria is increasing,2 with rates cited in the literature of between 20% and 40% to trimethoprim and amoxicillin respectively.3 Bacteria are adept at side-stepping human intervention (for example, antibiotics and vaccines) and are developing resistance to antibiotics faster than the pharmaceutical industry is developing new ones: only two new classes of antibiotics have been developed in the last 30 years.4 These problems highlight the need for high quality evidence to help primary care clinicians optimise the diagnosis and management of UTI. Fortunately, a plethora of high quality, clinically valuable, primary care research papers have been published recently, including four in the BMJ 5–8 and two in this month's BJGP .9,10 One of the BMJ papers reported that a range of management strategies (immediate versus delayed empirical antibiotics versus antibiotics guided by the results of dipstick versus symptom score versus midstream urine culture) achieved similar symptomatic results, while delayed empirical and dipstick-guided prescribing reduced antibiotic consumption.5 The authors concluded that there is ‘no advantage in routinely sending midstream urine [MSU] samples for [culture]’. This makes for an interesting and contrasting background to one of the papers reported in this month's BJGP ,9 which provides evidence in support of sending MSUs for culture. This study by Vellinga et al provides some original and novel evidence for a practice, I suspect, is commonly used in primary care: that of looking for a previous urine culture to guide the treatment of a current, suspected UTI. …