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Women should be able to get antibiotics for urinary tract infection without a prescription

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3441 (Published 14 July 2015) Cite this as: BMJ 2015;351:h3441
  1. Kyle Knox, general practitioner, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6NW
  1. kyle.knox{at}phc.ox.ac.uk

Uncomplicated cystitis is common and easily treated with drugs such as nitrofurantoin. Kyle Knox asks why women cannot treat themselves, without using up precious appointments in general practice

Acute uncomplicated urinary tract infections (AUUTIs) are common, especially in premenopausal, sexually active women, of whom about 30% will have been affected by age 26.1 AUUTIs usually resolve without sequelae and rarely progress to pyelonephritis, but they result in considerable morbidity, and the goal of treatment is to ameliorate the severity and duration of symptoms.

The management of these AUUTIs should be relatively uniform because the causes and responses to oral antimicrobials are known and predictable. Public Health England’s guidance on their management can be summarised in a simple flowchart, which requires little clinical assessment.2 In an era of ready access to information, increasing patient autonomy, and overstretched primary care services, therefore, it would seem a good idea for women to be able to access safe and effective treatment without the costs and delays associated with consulting a clinician to get a prescription.

Three million appointments a year

Cystitis in women is coded as the reason for about 1% of the 300 million general practice consultations held each year in the United Kingdom,3 and Escherichia coli is responsible for over 70% of these cases.4 A meta-analysis of 32 trials showed that a three day course of antimicrobials was as good as a 5-10 day course in achieving symptomatic cure.5 Long term (4-10 weeks) and short term (2-15 days) symptomatic cure rates were about 80% and 90%, respectively.

Conventional microbiological diagnosis of AUUTIs involves quantitative culture of a mid-stream sample of urine using thresholds defined more than 50 years ago. However, as many as half of all AUUTIs have bacterial counts below these thresholds,6 and strategies that include urine culture are less cost effective than empirical treatment.7

Because the goal of treatment is to improve the classic symptoms that most women are able to describe, strategies are now based on these, rather than on tests, to determine management. Three clinical variables (dysuria, nocturia, and cloudy urine) give a positive predictive value (PPV) of 82% for urinary tract infection,8 and, although dipstick testing had a higher PPV, it did not improve the negative predictive value. Therefore, for AUUTIs in non-pregnant women, UK guidelines now advocate an empirical three day course of nitrofurantoin or trimethoprim when a woman presents with more than two symptoms of AUUTI.2

Nitrofurantoin has been available since the 1950s and is generally well tolerated when used in short courses. Nausea and bloating are the most common side effects, and more serious adverse events are associated with longer courses. It should be avoided in people with an estimated glomerular filtration rate of less than 45 mL/min because it is renally excreted and will not achieve therapeutic concentrations in the urine. A seven day course of nitrofurantoin, with additional safeguards, can also be used to treat AUUTIs in pregnancy.9

However—despite clear guidance, characteristic clinical syndrome, and predictable efficacy and safety—nitrofurantoin remains available only on prescription. The current prescription-only approach does nothing to limit antimicrobial use but creates urgent demand in primary care, as well as an additional hurdle for women accessing safe and effective treatment.

Antimicrobial resistance has been compared to global warming because of its potentially apocalyptic impact on the UK10 with the spread of extended spectrum β lactamases (ESBLs), a family of enzymes that confers bacterial resistance to penicillins and cephalosporins—a particular threat to the management of AUUTIs.

Since 1998 the UK government has considered antimicrobial stewardship a priority and has produced 11 guidance documents on this, continuing with the Department of Health’s current antimicrobial resistance strategy for 2013-18. As a result the UK is in the lowest quarter of European countries regarding rates of outpatient antimicrobial prescriptions.

However, women will often try to avoid taking antibiotics for AUUTIs, to persevere with their symptoms, and to be open to alternative strategies.11 If these strategies fail and antibiotics are needed, it is reassuring that sensitivity to nitrofurantoin remains greater than 90% in bacterial isolates that cause AUUTIs from the community, after more than 50 years of using this antibiotic.4 This contrasts with resistance to ciprofloxacin of more than 90% in ESBL producing E coli in some communities.12

Already available over the counter

Pregnancy tests, emergency contraception, and antimalarial prophylaxis are commonly available in UK pharmacies, and pharmacists are central to assessing compliance and risks during opioid substitution therapy. These are examples of improving access to tests and treatment that involve complex health decisions safely, consistently, and conveniently in that setting. In addition, two antibiotics are already available from pharmacies without prescription in the UK: oral azithromycin for uncomplicated chlamydia infection and topical chloramphenicol for bacterial conjunctivitis.

A change in the regulations that govern access to nitrofurantoin would be worthwhile only if taken up by women seeking treatment. At less than £3 (€4.20; $4.75) for a three day course of treatment compared with £8.20 for a prescription, it seems unlikely that cost would be a deterrent. The weight that women attach to a clinician’s assessment with more convenient access to treatment is unclear, but it should be explored as part of the commitment to self care in the NHS’s plan for 2014-15.

Notes

Cite this as: BMJ 2015;351:h3441

Footnotes

  • Competing interests: Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I was supported by the National Institute for Health Research under its Oxford Biomedical Research Centre Infection Theme.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

References

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