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Practice 10-Minute Consultation

Uncomplicated urinary tract infection in women

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n725 (Published 30 March 2021) Cite this as: BMJ 2021;372:n725

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Re: Uncomplicated urinary tract infection in women

Dear Editor

In the systemic review of patients treated with placebo for acute UTI, Hoffman et al 2020 [1] report that 39% of patients continued to describe symptoms nine weeks after first presenting. Other meta-analyses on RCT data from antibiotic studies reported failed antibiotic responses in microbiological and symptomatic data in up to 28% and 37% of patients within four to 14 weeks of treatment [2]. What happens then, to these minorities (almost 40%) in the long-term? We do not know because we have not sought to find out. Perhaps we should we be concerned for them? The guidelines advise that their future management be navigated by reference to urinary dipsticks and MSU culture, two tests that are now discredited [3]. It is falsely believed by many that a negative MSU culture means no UTI, despite this being a base-rate fallacy exacerbated by the deficiencies of the test. There is evidence that humans do develop a chronic urinary infection caused by intracellular colonisation of the bladder urothelial cells [4] and murine studies imply the delayed or inadequate treatment of acute UTI may lead to this sorry state [5].

Perhaps it would be wise to pause a while to consider the almost 40% that would seem to be overlooked by our protocols. Rightly we are enthusiastic about limiting the use of antibiotics but what if in so doing, our lack of thought resulted in creating a worse scourge of chronic cystitis and recalcitrant bladder pain? This is not such an outlandish question; we can report seeing such people, in increasing numbers, their lives devastated, and all tracing the start of their suffering to an ordinary acute urine infection, apparently treated inadequately [6] .

1. Hoffmann, T., et al., Natural history of uncomplicated urinary tract infection without antibiotics: a systematic review. Br J Gen Pract, 2020. 70(699): p. e714-e722.
2. Milo, G., et al., Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane.Database.Syst.Rev., 2005(2): p. CD004682.
3. Sathiananthamoorthy, S., et al., Reassessment of Routine Midstream Culture in Diagnosis of Urinary Tract Infection. J Clin Microbiol, 2019. 57(3).
4. Horsley, H., et al., Enterococcus faecalis subverts and invades the host urothelium in patients with chronic urinary tract infection. PLoS One, 2013. 8(12): p. e83637.
5. Hannan, T.J., et al., Early severe inflammatory responses to uropathogenic E. coli predispose to chronic and recurrent urinary tract infection. PLoS.Pathog., 2010. 6(8): p. e1001042.
6. Swamy, S., et al., Recalcitrant chronic bladder pain and recurrent cystitis but negative urinalysis: What should we do? Int Urogynecol J, 2018. 29(7): p. 1035-1043.

Competing interests: No competing interests

21 April 2021
James Malone-Lee
Emeritus Professor of Medicine
UCL, London