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Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial

BMJ 2010; 340 doi: (Published 05 February 2010) Cite this as: BMJ 2010;340:c199
  1. P Little, professor of primary care research1,
  2. M V Moore, senior lecturer1,
  3. S Turner, trial manager1,
  4. K Rumsby, trial data coordinator1,
  5. G Warner, general practitioner2,
  6. J A Lowes, consultant microbiologist 3,
  7. H Smith, professor of primary care4,
  8. C Hawke, public health physician5,
  9. G Leydon, senior research fellow1,
  10. A Arscott, research assistant1,
  11. D Turner, health economics research fellow6,
  12. M Mullee, senior lecturer in medical statistics and director of RDSU7
  1. 1Primary Care Medical Group, Community Clinical Sciences Division, University of Southampton School of Medicine, Southampton SO16 5ST
  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. 6Wessex Institute, University of Southampton, Southampton
  7. 7Community Clinical Sciences Division, University of Southampton School of Medicine, Southampton General Hospital, Southampton SO16 6YD
  1. Correspondence to: P Little, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST p.little{at}


    Objective To assess the impact of different management strategies in urinary tract infections.

    Design Randomised controlled trial.

    Setting Primary care.

    Participants 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection.

    Intervention Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group.

    Main outcome measures Symptom severity (days 2 to 4) and duration, and use of antibiotics.

    Results Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration).

    Conclusion All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use.

    Study registration National Research Register N0484094184 ISRCTN: 03525333.


    • We are grateful for the time given by patients and clinicians. We thank Bayer for provision of the 8SG strips.

    • Contributors: PL and MVM had the original ideas 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, MVM, 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. The researchers are independent of the funders, and the funders were not involved in management or analysis of the project.

    • Competing interests: JAL has been paid to attend consultancy workshops by Bayer and is currently working in collaboration with Bayer in 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: No additional data available; the authors are willing to share data where appropriate—for example, for use in individual patient data meta-analysis.

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