Do failed UTI diagnoses put women on the AMR frontline?

Now that our healthcare policy makers have added UTI to the Government's Women’s Health Strategy it is time to highlight why so many UTI diagnoses fail: hit-and-miss urine collection prevails, due to overlooked and ignored guidelines.

Urine collection doesn’t excite our healthcare policy folk; nor does it excite the opinion formers and commentators. Making sure guideilnes are followed will not invest our clinical leadership with shiny accolades that add kudos to reputation. It will not be covered by the media because pee is a waste product that no one really likes to talk about. Yet this waste product is information-rich. It carries as much, if not more diagnostic clues to our health as its counterpart, blood.

We need to talk about urine.

“If you don’t make the effort to collect the urine specimen properly, all the clever stuff you do later is pretty pointless. It’s a case of rubbish in, rubbish out,” says a Senior Microbiologist at Barts’ Heath NHS Trust. “The need for change is likely to be politically driven, rather than scientifically.”??The science is evident, the political will is not.

The lack of adherence to or interest in urine collectio guidelines plus the lack of protocol for urine collection is causing persistent, widespread and expensive diagnostic failure that starts at Primary Care. For unreliable frontline diagnoses lead to critical conditions, hospital admissions, and expensive, complex treatment, not to mention the millions of patients who continue to suffer. This is not the fault of our hardworking and overstretched GPs and frontline nursing staff.??It is our healthcare leaders who persistently overlook the need to make it easy for guidelines to be found let alone followed. The note about needing recommended midstream or clean-catch urine is a page or two away from the diagnostic and treatment flowcharts provided by Public Health England and the NHS. "Take a urine sample" doesn't make the grade.

Urinary tract infection (UTI) is a condition largely suffered by women. The last relevant data to come out of the NHS Unplanned Admissions Committee cites untreated UTI as the cause of 184,000 unplanned hospital admissions that cost the NHS ￡434m to treat (2013/14). This is hardly surprising when we know that 20-30% of initial antibiotic prescribing for UTI fails (Chronic Urinary Tract Infection Campaign CUTIC).

The majority of these annual 15m diagnostic failures will relate to women, who with UTI, suffer the most pain, most time off work and loss of income, whilst being prescribed the highest rate of broad-spectrum antibiotics, putting us firmly in the front line of antibiotic immunity. The need for a robust protocol around urine analysis has become critical. Data from CUTIC tells us that:

• 1.4m women suffer from chronic bladder pain and urinary dysfunction
• 1 in 3 women will have a UTI by the age of 24
• 50% of dipstick tests don’t detect infection
• 70% of infections risk recurrence within a year
• 47% of Gram-negative blood infections have a urinary source and can lead to potentially fatal sepsis

NHS Improvement advises that 50% of the global rise in Antimicrobial Resistance (AMR) has a urinary cause; yet our health service still routinely relies on unreliable dipstick tests to indicate infection, leading to broad spectrum antibiotics remaining the first prescribing port of call; for the pregnant woman this is highly undesirable as it can extend life-long risk of antibiotic immunity to the unborn child.

Overuse of antibiotics is directly linked to the lack of a protocol for urine collection, transportation and analysis. National contamination rates are as high as 70% in some areas of the country, a postcode lottery situation that fails patients, microbiologists and the clinicians whose job it is to make people better. Non-invasive and cheap to collect, urine can help diagnose myriad conditions that cost the NHS billions of pounds. They include:

• Kidney stones, infection and disease
• Bladder cancer
• Diabetes mellitus
• Hypertension
• Liver disease
• Pre-eclampsia and other potentially serious pregnancy related conditions

We must challenge our policy makers and health leaders to make the changes necessary to this most basic diagnostic process, to save lives, save money and create a solid foundation upon which the evolution of diagnostic UTI medicine can flourish.?Right now, the available digital diagnostic UTI technology relies on hit-amd-miss urine collection and won’t improve anything.

If the basics are right, the rest can follow. If they are not, then healthcare leaders everywhere will keep flushing substantial healthcare finances down the loo.

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