• Question: The GPs I work with often have a tendency to give longer courses for respiratory tract infections and UTIs if a patient presents with persistent symptoms after completing the initial (often empirical) course. I appreciate this is quite a general question but in what cases would this approach be justified?

    Asked by athomson11 on 18 Nov 2015.
    • Photo: Michael Moore

      Michael Moore answered on 18 Nov 2015:

      For respiratory infections- I guess we are talking here about LRTI i.e. dominant cough- antibiotics have a modest effect on symptoms. In the Cochrane systematic review there were only minor benefits from antibiotics and the duration of cough was reduced by on average half a day (bearing in mind it is likely to last around 3 weeks in total). So patients will return with persistent symptoms because they have not understood the likely natural history of the illness, they are not better because the antibiotics were never going to help. Antibiotics are not justified for most patients even at the first consultation so unless you have a reasonable suspicion that they are developing pneumonia or they have some other reason for treatment they will not be justified at the second consultation. Why don’t you suggest your colleagues have a learning need and they could address this by doing the MARTI (managing acute respiratory illness) module accessed through the RCGP target website.

      For UTI the guidelines suggest that an empirical course of antibiotics is appropriate (without investigation) in women presenting with severe symptoms. If women re-present with persistent symptoms then I would suggest an MSU might be helpful to both confirm the presence of infection and identify if resistant bugs are present. Some women will have symptoms still after three days but they may still settle with time, women with a resistant bug will have a longer duration and may need a targeted second course. My view is that it is reasonable to give a longer course (5 or 7 days) but I am not aware of trial evidence to guide treatment in this instance.

    • Photo: Elizabeth Beech

      Elizabeth Beech answered on 18 Nov 2015:

      Hi athomson 11 I was asked this question today for UTIs in a practice nurse forum. There is a need to ensure patients really do rehydrate and use adequate analgesia and take the whole antibioitc course as prescribed (dosing and duration). If they re-present c/o persistent urinary symptoms I advise get a urine sample to check for sensitivities – and this will inform the next presentation if they present frequently. LRTIs will be symptomatic for up to 3 weeks with or without antibiotics and people need to know this, rest and take appropriate analgesia also. The TARGET Treating Your Infection leaflet provides these messages and is a really useful resource to use in these (and all) patients. Most people I speak to about LRTIs really do not seem to understand its a 3 week thing.

    • Photo: Cliodna McNulty

      Cliodna McNulty answered on 23 Nov 2015:

      In our study of acute uncomplicated UTI, 50% of patients who reconsulted in the first week after empirical treatment with trimethoprim had a resistant organism.
      If someone represents the most important thing to do is first to assess them, have the symptoms worsened? Also assess for signs of pyelonephritis or sepsis especially if they are post operative or have other risk factors or older. If symptoms are worsening (or not improving after 5 days) then test the urine and change the agent. In younger patients, I don’t think there is a need to give a longer course – unless they do have signs of pyelonepritis or sepsis.