Re: Uncomplicated urinary tract infection in women
Dear Editor
As a national patient organisation advocating for people with urinary tract infection (UTI), Chronic UTI Australia is responding to ‘Uncomplicated urinary tract infection in women’ (published on 30 March 2021). We offer our perspective not as experts in biology, medicine, statistics or economics, but from our lived experience of suffering with chronic or recurrent UTI and listening to hundreds of other people—mainly women—suffering the same way.
Most of the people we represent started their journey with an uncomplicated acute UTI as described in the Hoffman et al article. At some point they were failed by UTI diagnosis and/or treatment guidelines and addressing these failures is important.
We fully support the article’s focus on clinicians helping women make informed decisions about UTI management by adopting a shared decision-making conversation. However, for a patient to make an informed choice between immediate antibiotics (the only treatment currently available) or taking a ‘wait and see’ approach, all facts about UTIs must be presented—not just those that are convenient, topical or aligned with the physician’s preferences. It is well known doctors are under increasing pressure to reduce their antibiotic prescribing practices to conform with antimicrobial stewardship programs. We are concerned this could be translated in a way that unfairly influences a patient’s decision.
In the best interest of UTI patients, a responsible ‘wait and see’ approach should only be considered once a clinician has disclosed all known UTI evidence to ensure the patient can make a properly informed decision.
This is what we know:
- Dipstick and urine cultures are seriously flawed and not suitable to diagnose infection or identify the cause. (1,2)
- Symptoms, urinary signals and patient history are currently our best tools to diagnose UTI and monitor treatment outcomes. (3)
- Around 30 percent of people with UTIs have infections that spontaneously clear without antibiotic treatment—we do not know why. (4)
- There is no data available on how many self-resolving UTIs relapse after six weeks—we do not know.
- Over a third of people treated with standard antibiotic treatment for uncomplicated acute UTI fail to respond—we do not know why. (5,6)
- A subgroup of people presenting with uncomplicated acute UTI go on to develop recurrent or chronic UTI—we do not know why.
- There is currently no way to determine which group an individual will fall into—it is a game of chance.
- There is no data available on long-term harm caused by delaying antibiotic treatment in any UTI patient group—we do not know.
- The evidence for traditionally suggested self-management tips to prevent or cure UTI, such as wiping front to back, post-coital urination, drinking more water, consuming urinary alkalinising agents, cranberry products or probiotics, is insufficient or does not exist—we do not know how this came to be accepted medical advice. (7)
Expecting a patient to consider a ‘wait and see’ approach without being fully informed of the current evidence is to play Russian roulette with that patient’s health, but with far worse odds.
The paper by Hoffman et al also fails to consider the economic costs of the ‘wait and see’ approach, or the impacts on dependents such as children and the elderly. UTI is frequently trivialised but it is not a benign illness and significantly impacts quality of life. It is hard to imagine that a person with acute UTI—experiencing typical symptoms like severe and debilitating dysuria, suprapubic pain, urinary frequency, urgency and incontinence—would be well enough to work or perform their caring responsibilities during the ‘wait and see’ period. (4) The productivity of those that do would be severely limited. For the substantial proportion whose UTI does not clear spontaneously without antibiotic treatment, the period of lost or reduced productivity would be extended by days. For the smaller proportion whose infections progress and require hospitalisation with pyelonephritis or urosepsis, the costs are even greater.
To change the current trajectory of the growing health burden associated with UTI, we need better diagnosis and treatment of UTI. As experts-by-experience, patients need to be heard and involved in the solution.
Rapid Response:
Re: Uncomplicated urinary tract infection in women
Dear Editor
As a national patient organisation advocating for people with urinary tract infection (UTI), Chronic UTI Australia is responding to ‘Uncomplicated urinary tract infection in women’ (published on 30 March 2021). We offer our perspective not as experts in biology, medicine, statistics or economics, but from our lived experience of suffering with chronic or recurrent UTI and listening to hundreds of other people—mainly women—suffering the same way.
Most of the people we represent started their journey with an uncomplicated acute UTI as described in the Hoffman et al article. At some point they were failed by UTI diagnosis and/or treatment guidelines and addressing these failures is important.
We fully support the article’s focus on clinicians helping women make informed decisions about UTI management by adopting a shared decision-making conversation. However, for a patient to make an informed choice between immediate antibiotics (the only treatment currently available) or taking a ‘wait and see’ approach, all facts about UTIs must be presented—not just those that are convenient, topical or aligned with the physician’s preferences. It is well known doctors are under increasing pressure to reduce their antibiotic prescribing practices to conform with antimicrobial stewardship programs. We are concerned this could be translated in a way that unfairly influences a patient’s decision.
In the best interest of UTI patients, a responsible ‘wait and see’ approach should only be considered once a clinician has disclosed all known UTI evidence to ensure the patient can make a properly informed decision.
This is what we know:
- Dipstick and urine cultures are seriously flawed and not suitable to diagnose infection or identify the cause. (1,2)
- Symptoms, urinary signals and patient history are currently our best tools to diagnose UTI and monitor treatment outcomes. (3)
- Around 30 percent of people with UTIs have infections that spontaneously clear without antibiotic treatment—we do not know why. (4)
- There is no data available on how many self-resolving UTIs relapse after six weeks—we do not know.
- Over a third of people treated with standard antibiotic treatment for uncomplicated acute UTI fail to respond—we do not know why. (5,6)
- A subgroup of people presenting with uncomplicated acute UTI go on to develop recurrent or chronic UTI—we do not know why.
- There is currently no way to determine which group an individual will fall into—it is a game of chance.
- There is no data available on long-term harm caused by delaying antibiotic treatment in any UTI patient group—we do not know.
- The evidence for traditionally suggested self-management tips to prevent or cure UTI, such as wiping front to back, post-coital urination, drinking more water, consuming urinary alkalinising agents, cranberry products or probiotics, is insufficient or does not exist—we do not know how this came to be accepted medical advice. (7)
Expecting a patient to consider a ‘wait and see’ approach without being fully informed of the current evidence is to play Russian roulette with that patient’s health, but with far worse odds.
The paper by Hoffman et al also fails to consider the economic costs of the ‘wait and see’ approach, or the impacts on dependents such as children and the elderly. UTI is frequently trivialised but it is not a benign illness and significantly impacts quality of life. It is hard to imagine that a person with acute UTI—experiencing typical symptoms like severe and debilitating dysuria, suprapubic pain, urinary frequency, urgency and incontinence—would be well enough to work or perform their caring responsibilities during the ‘wait and see’ period. (4) The productivity of those that do would be severely limited. For the substantial proportion whose UTI does not clear spontaneously without antibiotic treatment, the period of lost or reduced productivity would be extended by days. For the smaller proportion whose infections progress and require hospitalisation with pyelonephritis or urosepsis, the costs are even greater.
To change the current trajectory of the growing health burden associated with UTI, we need better diagnosis and treatment of UTI. As experts-by-experience, patients need to be heard and involved in the solution.
(1) https://www.auajournals.org/doi/10.1016/j.juro.2010.01.008
(2) https://jcm.asm.org/content/early/2018/12/10/JCM.01452-18
(3) https://link.springer.com/article/10.1007/s00192-018-3569-7
(4) https://bjgp.org/content/70/699/e714
(5) https://pubmed.ncbi.nlm.nih.gov/20927755/
(6) https://www.bmj.com/content/359/bmj.j5766.full?ijkey=IiTCSBtWau0sm9j&key...
(7) https://journals.lww.com/fpmrs/Pages/articleviewer.aspx?year=2018&issue=...
Competing interests: No competing interests