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The Importance of Accurate Diagnosis

Watch the video to see Chris and Mandy discuss the importance of accurate diagnosis and the selection of the most appropriate antibiotics.
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I want to come back to this issue that you raised really importantly about diagnosis, because we tend to write into the computer Monday morning, hell breaking loose, UTI, trimethoprim or whatever. And actually, we don’t think further than that. And UTI is probably a range of syndromes. Pyelonephritis; people are really sick with fever, often blood, loin pain. If you’ve got a good going case of pyelonephritis, it’s not hard to spot.
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Cystitis in the bladder; they’re very uncomfortable, frequency, dysuria, often blood in the urine, nocturia. Can’t sit still. It’s very, very unpleasant, very uncomfortable. There’s the typical woman who comes in, is slightly agitated. And very few of us are not going to prescribe antibiotics for those two conditions. But then there’s urethritis, so irritation in the urethra. And that could be following sexual activity or a range of other things that could be irritating the urethra.
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And I think there, we’ve got a potential of making a lot of gains in terms of keeping antibiotics away from those who won’t benefit, and perhaps getting symptomatic treatment, which might help them get better a whole lot quicker, and save them all the risks to that individual person that comes with antibiotic prescribing. And around the antibiotics, you were making a strong pitch to start with? Nitrofurantoin. There are alternatives like pivmecillinam. That’s becoming increasingly used within the UK, particularly, if you’ve got an organism which is resistant or more resistant. So people with recurrent UTIs maybe that might be a good choice. What about trimethoprim? Well, I think the trimethoprim, it still can be used, and it has been first line.
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But I think with the increasing resistance rate, and the fact that nitrofurantoin’s resistance rate is so small, I think that’s probably the best first line antibiotic to use. But then when urines are cultured, it’s fine to use and you know what the sensitivity is, it’s fine to use trimethoprim or even amoxicillin. Yes, if you have the sensitivities then use them. I think what I would say is also, is that I would steer clear of broad spectrum antibiotics like co-amoxiclav. I would prefer narrow spectrum antibiotics. The reason nitrofurantoin is such a good antibiotic for UTI is because the levels are very, very high in the bladder. And so they’re high in places where it needs to work.
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So that’s why nitrofurantoin is such a good drug. But there is a danger with nitrofurantoin, isn’t it? We need to be a little bit careful. Yeah, you have to be careful in terms of what scenarios you’re going to use it in. Yeah, you’re right So the old, frail, sick person with renal failure, there would be a caution. But in the otherwise healthy woman, it’s a pretty safe drug.
Watch the video to see Chris and Mandy discuss the importance of accurate diagnosis and the selection of the most appropriate antibiotics.
The term Urinary Tract Infection covers a whole range of conditions from uncomplicated cystitis through to pyelonephritis and it is vital to choose the right antibiotic for the presenting condition or in the case of uncomplicated UTI, to treat the symptoms without the need for an antibiotic prescription.
When considering the correct antibiotic there is concern over the widespread use of trimethoprim due to the high resistance rates compared the relatively low resistance rates seen with nitrofurantoin.
Welsh resistance rates (.html) from 2014 to 2016 and the Scottish antimicrobial resistance data (.xlsx) from 2012 to 2015 show resistance in urinary tract infections to many of the commonly used antibiotics.
A very useful document is the Quick Reference Tool on the Diagnosis of UTI developed by Public Health England.
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