JAC Advance Access published online on September 23, 2006
Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkl368
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1 Health Protection Agency Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
* To whom correspondence should be addressed. 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 ( 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.
Received February 8, 2006
Revised July 24, 2006
Accepted August 15, 2006
Original article
Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care
C. A. M. McNulty 1 *, J. Richards 2, D. M. Livermore 3, P. Little 4, A. Charlett 3, E. Freeman 5, I. Harvey 6, and M. Thomas 7
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; Minchinhampton Surgery, Strand, UK
C. A. M. McNulty, E-mail: cliodna.mcnulty{at}hpa.org.uk
Abstract 
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).
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