A group of linked trials published in the BMJ examine strategies for managing uncomplicated urinary tract infections (UTI) in women presenting in primary care; the basic study compares five different commonly-used strategies, and this is complemented by an economic analysis, an observational study of the natural course and symptoms of the condition, and a qualitative study of patients’ experiences of treatment.

This article covers the observational study and the qualitative analysis of women’s views and experiences of treatment.

The aim of the observational study was to assess the natural course of the infection, and identify factors that were important predictors of severe symptoms; in addition, the authors investigated the effect of antibiotics and antibiotic resistance. It was nested within the randomised trial but was independent of the study cohort. The authors note that there is currently limited information on the natural course and symptom pattern in patients presenting with symptoms and no bacterial growth in culture (the urethral syndrome), or on the impact of antibiotic resistance or of not prescribing antibiotics. Participants were non-pregnant women aged 18 to 75 presenting in primary care with symptoms of uncomplicated UTI. They were asked to provide a midstream urine specimen and to keep a daily diary of symptoms (graded 0 to 6 where 6 is worst) for up to 14 days. Finally, they completed a questionnaire on their perceptions about communication during their consultation.

Of those patients approached and eligible, over 90% agreed to participate: there were 843, of whom 839 supplied urine specimens. There was information on baseline symptoms for 830 women; 81% provided some information on duration of symptoms, 64% (541) returned more complete symptom diaries and 511 had both laboratory results and complete symptom diaries.

For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, factors associated with longer duration of moderately bad symptoms were antibiotic-resistant infections (incidence rate ratio [IRR]1.56, 95% CI 1.22 to 1.99, P<0.001); antibiotic non-prescription (IRR 1.62; 95% CI 1.13 to 2.31; P=0.008); and presence of the urethral syndrome (IRR, 1.33; 95% CI, 1.14 to 1.56; P<0.001). Other factors associated with longer duration were frequent somatic symptoms (IRR 1.03; 95% CI, 1.01 to 1.05; P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline.

Symptom duration was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91; 95% CI 0.84 to 0.99; P=0.021).

The authors conclude that in this patient group, not prescribing antibiotics, and infection due to antibiotic resistant organisms were associated with longer duration of symptoms. Patient factors that predicted a longer duration were a history of cystitis, frequent somatisation, and severe symptoms at baseline; such patients can be counselled that they are more likely to have symptoms for over three days.

The qualitative study obtained in-depth information on the women’s views about their illness and its management using semi-structured one-to-one interviews. Participants had been randomised to the main trial and were in a group in which delayed antibiotic prescription was specified. The interview data were transcribed and analysed to determine themes grounded in reported experiences and understandings.

There were 33 women approached to participate, of whom 27 agreed and 21 were actually interviewed; due to a technical failure, 20 interviews were available for analysis. Themes identified included a willingness to avoid taking antibiotics, providing the woman felt that her condition had been taken seriously by the clinician. There was concern over antibiotic side effects, and UTI was attributed to lifestyle factors and behaviours.

The authors note the themes identified, and comment that if women are asked to delay taking antibiotics, the rationale for this should be fully explained and their worries should be addressed.

The author of the accompanying editorial comments on the fact that how care is provided matters, not just what is done. A positive approach from the doctor was associated with a shorter duration of symptoms, whereas use of what seemed to be a patient-centred approach had no effect.

The NPC have also published an iblog discussing these studies.