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Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study

BMJ 2010; 340 doi: (Published 05 February 2010) Cite this as: BMJ 2010;340:b5633
  1. P Little, professor of primary care research1,
  2. R Merriman, medical student1,
  3. S Turner, study manager1,
  4. K Rumsby, study data coordinator1,
  5. G Warner, general practitioner2,
  6. J A Lowes, consultant microbiologist3,
  7. H Smith, professor of primary care4,
  8. C Hawke, public health physician5,
  9. G Leydon, senior postdoctoral research fellow1,
  10. M Mullee, senior lecturer in medical statistics and director of RDSU 6,
  11. M V Moore, senior lecturer1
  1. 1Primary Care Medical Group, Community Clinical Sciences Division (CCS), School of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 6ST
  2. 2Nightingale Surgery, Romsey, SO51 7QN
  3. 3Southampton Universities Hospital Trust Microbiology Laboratory, Southampton General Hospital, Southampton SO16 6YD
  4. 4Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX
  5. 5School of Rural Health, University of Sydney, Orange Campus, PO Box 1191, Orange, NSW, Australia
  6. 6Community Clinical Sciences Division (CCS), School of Medicine, University of Southampton, Public Health Sciences and Medical Statistics Group, Southampton General Hospital, Southampton SO16 6YD
  1. Correspondence to: P Little, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST p.little{at}
  • Accepted 15 November 2009


Objective To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance.

Design Observational study.

Setting Primary care.

Participants 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection.

Main outcome measure Duration and severity of symptoms.

Results 684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline.

Conclusion Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.


  • We are very grateful for the time given by patients, general practitioners, and nurses. We are grateful to Bayer for provision of the 8SG strips.

  • Contributors: PL and MVM had the original idea for the study. All authors developed the protocol. ST ran the study on a day to day basis. KR managed the database. PL and MM performed the analysis. PL and MM are guarantors. All authors contributed to writing the paper

  • Funding: This study was funded by the health technology programme of UK NHS Research and Development.

  • Competing interests: JAL has been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in an unpaid capacity.

  • Ethical approval: This study was approved by the South West MReC ethics committee and informed consent was given by all patients.

  • Data sharing: The authors are happy to share data when appropriate—for example, for meta-analyses; requests to the corresponding author.

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