Family Practice Vol. 20, No. 4, 492
© Oxford University Press 2003
Correspondence |
Managing acute cystitis in women—are we mistreating?
Section for General Practice Ulriksdal 8C, N-5009 Bergen, Norway
I read with great interest the article by Tom Fahey and co-workers in the January 2003 issue of Family Practice.1 The authors report from a prospective study on how GPs diagnose and treat female patients consulting for urinary tract infection (UTI). I presume the authors mean lower UTI or cystitis, which is the term I will use below. Most women consulting for UTI in general practice have an acute uncomplicated cystitis.
The authors find that GPs mostly base the diagnosis on symptoms alone and treat empirically. Defining the ‘gold standard’ for cystitis as positive urine culture, they find that 75% of the patients receiving treatment have negative culture. They conclude that current clinical practice results in a large proportion of patients receiving unnecessary antibiotic treatment, and that individual symptoms of cystitis are an inadequate guide for decisions on diagnostic testing and antibiotic treatment in primary care.
Their conclusions are, however, not reflected in current literature.2 One reason may be that ‘positive urine culture’, undefined by the authors but usually defined as 
104–105 colony-forming units (c.f.u.)/ml, has never been proved as a gold standard for cystitis. Kass and Finland established 105 c.f.u./ml as the best cut-off for pyelonephritis and asymptomatic bacteriuria.3 The problem is that medical culture has adopted the same cut-offs for acute uncomplicated cystitis in women without any documentation. Stamm et al. readdressed the problem in 1982,4 showing that women with uncomplicated cystitis may have bacterial counts in the urine as low as 102 c.f.u./ml. Bacteriuria on this level cannot be tested reliably in voided urine or by routine laboratory methods. The practical consequence of Stamm’s findings then is that many women with cystitis (up to 50% in some materials) will have ‘sterile’ urine or low-count bacteriuria and may be categorized unduly as suffering from something else.
The authors use ‘re-consultation within a month for the same symptoms’ as their second gold standard. I find it hard to follow their reasoning at this point. A revisit with similar symptoms should indicate either a relapse (treatment failure) or a reinfection. The authors do not differentiate between these two conditions. Further, neither of these outcomes may indicate whether the patients had a ‘true’ cystitis at the first visit.
A recent study has shown that the clinical outcome after antibacterial treatment, measured as time from start of antibacterial treatment to relief of symptoms, is the same whether the cystitic women have bacteriuria or not.5 In other words, the degree of bacteriuria is not related to the clinical outcome by antimicrobial treatment in uncomplicated cystitis in otherwise healthy women.
In general practice, treatment may safely be based on typical symptoms alone, a strategy which also is economically cost-effective.6 Short duration treatment (3 days or less) is effective and does not readily result in increased bacterial resistance.
In my opinion, the authors could just as well have concluded that the participating GPs were largely updated in their diagnostic strategies, treating women with acute cystitis mainly according to best available knowledge.
References
1 Fahey T, Webb E, Montgomery AA, Heyderman RS. Clinical management of urinary tract infection in women: a prospective cohort study. Fam Pract 2003; 20: 1–6.
2 Bent S, Nallamothu BK, Simel DL, Fihn SD, Saint S. Does this woman have an acute uncomplicated urinary tract infection? J Am Med Assoc 2002; 287: 2701–2710.
3 Kass EH, Finland M. Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956; 69: 56–64.[Web of Science][Medline]
4 Stamm WE, Counts GW, Running KR, Fihn S, Turc M, Holmes KK. Diagnosis of coliform infection in acutely dysuric women. N Engl J Med 1982; 307: 463–468.[Abstract]
5 Baerheim A, Digranes Ø, Hunskaar S. Equal symptomatic outcome after antibacterial treatment of acute lower urinary tract infection and the acute urethral syndrome in adult women. Scand J Prim Health Care 1999; 17: 170–173.[CrossRef][Web of Science][Medline]
6 Bent S, Saint S. The optimal use of diagnostic testing in women with acute uncomplicated cystitis. Am J Med 2002; 113: 20S–28S.
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