JAC Advance Access originally published online on September 23, 2006
Journal of Antimicrobial Chemotherapy 2006 58(5):1000-1008; doi:10.1093/jac/dkl368
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Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care
1 Health Protection Agency Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital Great Western Road, Gloucester GL1 3NN, UK 2 Microbiology Department, Norfolk and Norwich University Hospital NHS Trust Norwich, UK 3 Health Protection Agency Centre for Infections London, UK 4 Department of Primary Care, University of Southampton Southampton, UK 5 Gloucestershire Research & Development Support Unit Gloucester, UK 6 School of Medicine, Health Policy & Practice, University of East Anglia Norwich, UK 7 Department of General Practice, University of Aberdeen Aberdeen, UK 8 Minchinhampton Surgery Strand, UK
Received 8 February 2006; returned 25 March 2006; revised 24 July 2006; accepted 15 August 2006
*Corresponding author. Tel: +44-8454-225061; Fax: +44-1452-526197; E-mail: cliodna.mcnulty{at}hpa.org.uk
Objectives: To determine whether patients with an uncomplicated community-acquired urinary tract infection (UTI) and an isolate resistant to trimethoprim had worse clinical outcomes following empirical treatment with trimethoprim 200 mg twice daily for 3 days than did those with a susceptible isolate.
Patients and methods: This was a prospective cohort study of clinical outcome. We enrolled 497 women (
18–70 years) presenting to general practitioner surgeries in Norwich and Gloucester with at least two symptoms of acute (<7 days) uncomplicated UTI. Significant bacteriuria was defined as 104 cfu/mL from a mid-stream urine (MSU).
Results: Of enrolled patients 75% (334/448) had significant bacteriuria, and trimethoprim resistance was present in 13.9% (44/317) of isolates. Patients with resistant isolates had a longer median time to symptom resolution (7 versus 4 days, P = 0.0002), greater reconsultation to the practice (39% versus 6% in first week, P < 0.0001), more subsequent antibiotics (36% versus 4% in first week, P < 0.0001) and higher rates of significant bacteriuria at 1 month (42% versus 20% with susceptible isolate, P = 0.04). Half of patients reconsulting in the first week had a resistant organism.
Conclusions: Patients with uncomplicated UTI caused by trimethoprim-resistant organisms had significantly worse clinical outcomes than those with trimethoprim-susceptible organisms. Nevertheless, trimethoprim resistance was rarer than predicted from routine laboratory submissions and we calculate that 23 women require microbiological investigation to prevent one reconsultation arising from resistance-based treatment failure. We therefore suggest empirical antibiotic treatment in acute, uncomplicated UTIs. If patients reconsult in the first week, we suggest a change of antibiotic treatment with urine culture and susceptibility testing then done. More generally, laboratory resources should concentrate on resistance surveillance to inform empirical antibiotic choice.
Keywords: UTI , clinical outcome , trimethoprim , community/primary care , cohort
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