Abstract Background Urinary infection in otherwise healthy women has largely been a straightforward matter of diagnosis by identifying bacteria in the urine, and then cure by appropriate antibiotics. Recent research has shown this to be over-simplified. Evaluation of methods of self-management of symptoms has been neglected. Discussion Firstly trial data show that women with what used to called 'urethral syndrome' (urinary symptoms but sterile urine) obtain relief from antibiotics. Other trial data have shown a surprisingly large placebo effect from the resolution of symptoms among women who feel their care has been 'positive'. In addition, data published this month in <it>BMC Medicine </it>show that non-steroidal anti-inflammatory (NSAID) drugs provide symptom relief to women with conventional infections (positive urine bacteriology) as much as antibiotics. Conclusions These recent findings provide an opportunity to consider how clinicians might change practice, and sets a new research agenda. We need to know (1) whether the effect of NSAIDs is replicable; (2) why some women in previous trials have had more symptoms if not treated with antibiotics sooner; (3) whether NSAIDs and antibiotics have an additive effect on relieving symptoms; (4) how we can harness the placebo effect better to assist out patients with this distressing and common complaint. See research article <url>http://www.biomedcentral.com/1741-7015/8/30</url></p

American College of Obstetricians and Gynecologists (ACOG)

C Del Mar

Chris Del Mar

D Richards

EE Moore

G Fowler

J Bleidorm

JN Krieger

NC Stott

P Little

R Arav-Boger

RG Jepson

Scottish Intercollegiate Guidelines Network (SIGN)

SL Jackson

TM Hooton

W Brumfitt

WL Deville

English

PubMed

Background. Urinary infection in otherwise healthy women has largely been a straightforward matter of diagnosis by identifying bacteria in the urine, and then cure by appropriate antibiotics. Recent research has shown this to be over-simplified. Evaluation of methods of self-management of symptoms has been neglected. Discussion. Firstly trial data show that women with what used to called 'urethral syndrome' (urinary symptoms but sterile urine) obtain relief from antibiotics. Other trial data have shown a surprisingly large placebo effect from the resolution of symptoms among women who feel their care has been 'positive'. In addition, data published this month in BMC Medicine show that non-steroidal anti-inflammatory (NSAID) drugs provide symptom relief to women with conventional infections (positive urine bacteriology) as much as antibiotics. Conclusions. These recent findings provide an opportunity to consider how clinicians might change practice, and sets a new research agenda. We need to know (1) whether the effect of NSAIDs is replicable; (2) why some women in previous trials have had more symptoms if not treated with antibiotics sooner; (3) whether NSAIDs and antibiotics have an additive effect on relieving symptoms; (4) how we can harness the placebo effect better to assist out patients with this distressing and common complaint.</p

Del Mar, Chris

Bond University Research Portal

Bond UniversityResearch RepositoryUrinary tract infections in healthy womenDel Mar, ChrisPublished in:BMC Family PracticeDOI:10.1186/1471-2296-11-42Published: 01/01/2010Document Version:Publisher's PDF, also known as Version of recordLink to publication in Bond University research repository.Recommended citation(APA):Del Mar, C. (2010). Urinary tract infections in healthy women: A revolution in management? BMC FamilyPractice, 11, [42]. https://doi.org/10.1186/1471-2296-11-42General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.For more information, or if you believe that this document breaches copyright, please contact the Bond University research repositorycoordinator.Download date: 06 Nov 2019Del Mar BMC Family Practice 2010, 11:42http://www.biomedcentral.com/1471-2296/11/42Open AccessC O M M E N T A R YCommentaryUrinary tract infections in healthy women: a revolution in management?Chris Del MarAbstractBackground: Urinary infection in otherwise healthy women has largely been a straightforward matter of diagnosis by identifying bacteria in the urine, and then cure by appropriate antibiotics. Recent research has shown this to be over-simplified. Evaluation of methods of self-management of symptoms has been neglected.Discussion: Firstly trial data show that women with what used to called 'urethral syndrome' (urinary symptoms but sterile urine) obtain relief from antibiotics. Other trial data have shown a surprisingly large placebo effect from the resolution of symptoms among women who feel their care has been 'positive'. In addition, data published this month in BMC Medicine show that non-steroidal anti-inflammatory (NSAID) drugs provide symptom relief to women with conventional infections (positive urine bacteriology) as much as antibiotics.Conclusions: These recent findings provide an opportunity to consider how clinicians might change practice, and sets a new research agenda. We need to know (1) whether the effect of NSAIDs is replicable; (2) why some women in previous trials have had more symptoms if not treated with antibiotics sooner; (3) whether NSAIDs and antibiotics have an additive effect on relieving symptoms; (4) how we can harness the placebo effect better to assist out patients with this distressing and common complaint.See research article http://www.biomedcentral.com/1741-7015/8/30IntroductionUrinary infections are very common among otherwisehealthy women: a very high number experience symp-toms and will have sought treatment before the age of 40.Among the aetiological actors, being sexually activeseems to be the most important, both before and aftermenopause [1-3]. Diabetes is a well-known risk factor [4].There is little that can be done to prevent urinary infec-tions in healthy women. Therefore most attention isfocussed on treating infections as they arise.Although asymptomatic bacteriuria is a predictor foran increased risk of subsequently experiencing symptom-atic urinary infections later, there is not regarded as astrong association enough to warrant screening [4](except in antenatal care, recurrent infections or anatom-ical abnormality - not under consideration here).DiagnosisDiagnosis has been considered straightforward in thepast. The presence of bacteria on urine culture has beenregarded as the gold standard. There has been discussionabout the use of urine dipsticks (particularly with stripsfor testing for nitrites and leukocyte esterase) to guidetreatment before results of cultures are returned. Urinedipsticks are useful for ruling out disease [5,6], and therehas been a good argument for treating otherwise healthywomen with antibiotics empirically if dipsticks are posi-tive [5].If there were no bacteria found on culture, an infectivecause for the symptoms seemed unlikely. This led to thegeneration of a new term for 'culture-negative symptomsof urinary frequency, urgency and dysuria', called 'ure-thral syndrome', regarded as difficult to treat [7].Conventional treatmentConventional treatment has principally focussed on erad-icating bacterial causes. This seems on first considerationto be entirely logical: the urine is normally sterile, andsymptoms of infection (frequency, and dysuria especially)* Correspondence: cdelmar@bond.edu.au1 School of Medicine, Faculty of Health Sciences, Bond University, Queensland 4229, AustraliaFull list of author information is available at the end of the articleBioMed Central© 2010 Del Mar; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons At-tribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in anymedium, provided the original work is properly cited.Del Mar BMC Family Practice 2010, 11:42http://www.biomedcentral.com/1471-2296/11/42Page 2 of 3are relieved after the bacteria have been cleared. Mostorganisms (and Escherichia coli among the faecal bacteriaby far the most common) are responsive to cheap andavailable antibiotics.Consequently, the focus of interest in the medical liter-ature has been on selecting the appropriate antibiotic, thetension existing between ensuring the likelihood of effec-tiveness of the antibiotic, and minimising antibiotic resis-tance in the community.This approach has been turned on its head by the sur-prising finding of a randomised controlled trial (RCT) inthe recent past of women with symptoms of urinaryinfection, but negative findings for bacteria in the urine[8]. The RCT found benefit for symptoms with antibioticover no antibiotics - even when conventional wisdom hadheld that they were not infected by bacteria (but had whatmight have been called 'urethral syndrome' in the past)[8].On the other side of the coin, women with urinaryinfections randomised to delay taking antibiotics by twodays suffer only about a day or two more of symptoms [9].In other words, we can think of UTI as a spontaneouslyremitting disease, if we use symptoms (rather than steril-ity of the urine[10]) as the end-point, which is acceleratedby the use of antibiotics.A prognosis study has shown that the psychologicalstate of the woman is important - those with 'somatisa-tion' (exaggerated feelings of symptoms ) are likely toovercome their symptoms slower, while those who per-ceived the doctor to be positive about quickly overcomingsymptoms recovered faster [9].Like so much in medicine, the arena is messy, withmany factors influencing recovery.One thing is clear: whether treatment should be aimedat eliminating bacteria from the urine or not, certainlytreatment of the symptoms warrants attention.The evidenceThis is then a fertile time to think about using symptomscontrol rather than 'bacterial eradication' as an approach.Urinary alkalinisers self managementIt has been traditional to use urinary alkalinisers in thepast as symptomatic relief (by the simple expedient oftaking sodium or potassium bicarbonate or other alkalineby mouth) [11]. This is remarkably poorly evaluated inthe medical literature [12]. An observational study foundsymptom severity within each woman's illness was notassociated with increases in urinary pH, suggesting alka-linising the urine is unlikely to reduce symptoms [12]. Afactorial randomised trial which randomised yielded nodifference to those randomised to advice to use bicarbon-ate or not [5].Cranberry juice self managementAlthough cranberry juice is a well used 'alternative andcomplementary medicine' for urinary tract infection, andthere is weak and contradictory evidence it might act as apreventive agent [13], there is insufficient good qualitytrial evidence to support its use as a treatment [14]. Onegood RCT has been published recently to suggest that itis not [5].Non-steroidal anti-inflammatory (NSAIDs) drugsThese are commonly used for pain and inflammatoryconditions, and, although NSAIDs have adverse effects,they are regarded as sufficiently safe to be available inmost jurisdictions over-the-counter without prescription.The pragmatic trial published this month in BMC Med-icine by Bleidorn and colleagues [15] randomised antimi-crobial treatment against symptomatic treatment (in theform of a non-steroidal anti-inflammatory drug) for uri-nary symptoms. The treatments were equivalent not justin the outcome of symptoms (which might have been pre-dicted), but in the outcome of subsequent urinary infec-tions. Why is this revolutionary? Because it turns on itshead the notion that we should regard urinary infectionsas primarily an infectious process that needs sterilisationof the urine to effect resolution.It used to be thought that urinary infections were suffi-ciently unusual and bizarre to requite extermination ofthe bacterial intruder. However two things have alteredthis approach. Firstly we recognise that some people(especially the elderly) often have bacteriuria with no illeffect, including no symptoms: treating them with antibi-otics achieves only bacterial resistance. More recently wehave come to realise that women who have urinary symp-toms but no evidence of bacterial infection detected onurinary dip-stick - women who would have accordinglybeen denied antibiotics using traditional treatments -benefit symptomatically from antibiotics [8]. Guidelineshave adjusted to this in some quarters[16] (but notall[17]).ConclusionsCompeting interestsThe author declares that they have no competing interests.Authors' informationCDM is professor of primary care research at Bond University, Australia. He is also the coordinating editor of the Cochrane Collaboration's acute respiratory infection group.Author DetailsSchool of Medicine, Faculty of Health Sciences, Bond University, Queensland 4229, AustraliaReceived: 15 April 2010 Accepted: 26 May 2010 Published: 26 May 2010This article is available from: http://www.biomedcentral.com/1471-2296/11/42© 2010 D l M r; l censee BioMed Central Ltd. is an Open Acces  article distribu ed under th  terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BMC Family Pract  2010, 11:42Del Mar BMC Family Practice 2010, 11:42http://www.biomedcentral.com/1471-2296/11/42Page 3 of 3References1. Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, Stergachis A, Stamm WE: A prospective study of risk factors for symptomatic urinary tract infection in young women.  N Engl J Med 1996, 335:468-474.2. Moore EE, Hawes SE, Scholes D, Boyko EJ, Hughes JP, Fihn SD: Sexual intercourse and risk of symptomatic urinary tract infection in post-menopausal women.  J Gen Intern Med 2008, 23:595-599.3. Krieger JN: Urinary tract infections what's new?  J Urol 2002, 168:2351-2358.4. Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD: Predictors of urinary tract infection after menopause a prospective study.  Am J Med 2004, 117:903-911.5. Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, Smith H, Hawke C, Turner D, Leydon GM, Arscott A, Mullee M: Dipsticks and diagnostic algorithms in urinary tract infection development and validation, randomised trial, economic analysis, observational cohort and qualitative study.  Health Technol Assess 2009, 13:iii-iv. ix-xi, 1-736. Deville WL, Yzermans JC, van Duijn NP, Bezemer PD, Windt DA van der, Bouter LM: The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy.  BMC Urol 2004, 4:4.7. Editorial: Urethral syndrome.  BMJ 1968, 2:192.8. Richards D, Toop L, Chambers S, Fletcher L: Response to antibiotics of women with symptoms of urinary tract infection but negative dipstick urine test results double blind randomised controlled trial.  BMJ 2005, 331:143.9. Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, Smith H, Hawke C, Leydon G, Mullee M, Moore MV: Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care observational study.  BMJ 2010, 340:b5633.10. Arav-Boger R, Leibovici L, Danon YL: Urinary tract infections with low and high colony counts in young women. Spontaneous remission and single-dose vs multiple-day treatment.  Arch Intern Med 1994, 154:300-304.11. Therapuetic Guidelines  2009 [http://www.tg.org.au/index.php?sectionid=1]. Therapuetic Guidelines Limited ed. Melbourne 7 Mar 201012. Brumfitt W, Hamilton-Miller JM, Cooper J, Raeburn A: Relationship of urinary pH to symptoms of 'cystitis'.  Postgrad Med J 1990, 66:727-729.13. Jepson RG, Craig JC: Cranberries for preventing urinary tract infections.  Cochrane Database Syst Rev 2008:CD001321.14. Jepson RG, Mihaljevic L, Craig J: Cranberries for treating urinary tract infections.  Cochrane Database Syst Rev 2000:CD001322.15. Bleidorm J, Gagyor I, Kochen M, Wegscheider K, Hummers-Pradie E: Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for uncomplicated urinary tract infection? - Results of a randomized controlled pilot trial.  BMC Medicine 2010, 8:30.16. Scottish Intercollegiate Guidelines Network (SIGN): 88: Management of suspected bacterial urinary tract infection in adults.  2006 [http://www.sign.ac.uk/pdf/sign88.pdf]. (accessed 5 Apr 2010)17. American College of Obstetricians and Gynecologists (ACOG): Treatment of urinary tract infections in nonpregnant women (ACOG practice bulletin; no. 91).  2008 [http://www.guideline.gov/summary/summary.aspx?doc_id=12628&nbr=006536&string=urinary+AND+infection]. (accecssed 5 April 2010)18. Fowler G: The role of the primary health care team.  J R Soc Med 1986, 79:633-636.19. Stott NC: William Pickles Lecture 1993. When something is good, more of the same is not always better.  Br J Gen Pract 1993, 43:254-258.20. Del Mar C, Glasziou P: Upper respiratory tract infection.  Clin Evid 2004, 11:1956-1965.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/42/prepubdoi: 10.1186/1471-2296-11-42Cite this article as: Del Mar, Urinary tract infections in healthy women: a rev-olution in management? BMC Family Practice 2010, 11:42

Urinary tract infections in healthy women:A revolution in management?

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Urinary tract infections in healthy women: a revolution in management?

Abstract Background Urinary infection in otherwise healthy women has largely been a straightforward matter of diagnosis by identifying bacteria in the urine, and then cure by appropriate antibiotics. Recent research has shown this to be over-simplified. Evaluation of methods of self-management of symptoms has been neglected. Discussion Firstly trial data show that women with what used to called 'urethral syndrome' (urinary symptoms but sterile urine) obtain relief from antibiotics. Other trial data have shown a surprisingly large placebo effect from the resolution of symptoms among women who feel their care has been 'positive'. In addition, data published this month in BMC Medicine show that non-steroidal anti-inflammatory (NSAID) drugs provide symptom relief to women with conventional infections (positive urine bacteriology) as much as antibiotics. Conclusions These recent findings provide an opportunity to consider how clinicians might change practice, and sets a new research agenda. We need to know (1) whether the effect of NSAIDs is replicable; (2) why some women in previous trials have had more symptoms if not treated with antibiotics sooner; (3) whether NSAIDs and antibiotics have an additive effect on relieving symptoms; (4) how we can harness the placebo effect better to assist out patients with this distressing and common complaint. See research article http://www.biomedcentral.com/1741-7015/8/30</p

Del Mar Chris

Directory of Open Access Journals

BMC Family Practice

Del Mar BMC Family Practice 2010, 11:42
http://www.biomedcentral.com/1471-2296/11/42
Open AccessC O M M E N T A R YCommentaryUrinary tract infections in healthy women: a 
revolution in management?
Chris Del Mar
Abstract
Background: Urinary infection in otherwise healthy women has largely been a straightforward matter of diagnosis by 
identifying bacteria in the urine, and then cure by appropriate antibiotics. Recent research has shown this to be over-
simplified. Evaluation of methods of self-management of symptoms has been neglected.
Discussion: Firstly trial data show that women with what used to called 'urethral syndrome' (urinary symptoms but 
sterile urine) obtain relief from antibiotics. Other trial data have shown a surprisingly large placebo effect from the 
resolution of symptoms among women who feel their care has been 'positive'. In addition, data published this month 
in BMC Medicine show that non-steroidal anti-inflammatory (NSAID) drugs provide symptom relief to women with 
conventional infections (positive urine bacteriology) as much as antibiotics.
Conclusions: These recent findings provide an opportunity to consider how clinicians might change practice, and sets 
a new research agenda. We need to know (1) whether the effect of NSAIDs is replicable; (2) why some women in 
previous trials have had more symptoms if not treated with antibiotics sooner; (3) whether NSAIDs and antibiotics have 
an additive effect on relieving symptoms; (4) how we can harness the placebo effect better to assist out patients with 
this distressing and common complaint.
See research article http://www.biomedcentral.com/1741-7015/8/30
Introduction
Urinary infections are very common among otherwise
healthy women: a very high number experience symp-
toms and will have sought treatment before the age of 40.
Among the aetiological actors, being sexually active
seems to be the most important, both before and after
menopause [1-3]. Diabetes is a well-known risk factor [4].
There is little that can be done to prevent urinary infec-
tions in healthy women. Therefore most attention is
focussed on treating infections as they arise.
Although asymptomatic bacteriuria is a predictor for
an increased risk of subsequently experiencing symptom-
atic urinary infections later, there is not regarded as a
strong association enough to warrant screening [4]
(except in antenatal care, recurrent infections or anatom-
ical abnormality - not under consideration here).
Diagnosis
Diagnosis has been considered straightforward in the
past. The presence of bacteria on urine culture has been
regarded as the gold standard. There has been discussion
about the use of urine dipsticks (particularly with strips
for testing for nitrites and leukocyte esterase) to guide
treatment before results of cultures are returned. Urine
dipsticks are useful for ruling out disease [5,6], and there
has been a good argument for treating otherwise healthy
women with antibiotics empirically if dipsticks are posi-
tive [5].
If there were no bacteria found on culture, an infective
cause for the symptoms seemed unlikely. This led to the
generation of a new term for 'culture-negative symptoms
of urinary frequency, urgency and dysuria', called 'ure-
thral syndrome', regarded as difficult to treat [7].
Conventional treatment
Conventional treatment has principally focussed on erad-
icating bacterial causes. This seems on first consideration
to be entirely logical: the urine is normally sterile, and
symptoms of infection (frequency, and dysuria especially)
* Correspondence: cdelmar@bond.edu.au
1 School of Medicine, Faculty of Health Sciences, Bond University, Queensland 
4229, Australia
Full list of author information is available at the end of the articleBioMed Central
© 2010 Del Mar; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons At-
tribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Del Mar BMC Family Practice 2010, 11:42
http://www.biomedcentral.com/1471-2296/11/42
Page 2 of 3are relieved after the bacteria have been cleared. Most
organisms (and Escherichia coli among the faecal bacteria
by far the most common) are responsive to cheap and
available antibiotics.
Consequently, the focus of interest in the medical liter-
ature has been on selecting the appropriate antibiotic, the
tension existing between ensuring the likelihood of effec-
tiveness of the antibiotic, and minimising antibiotic resis-
tance in the community.
This approach has been turned on its head by the sur-
prising finding of a randomised controlled trial (RCT) in
the recent past of women with symptoms of urinary
infection, but negative findings for bacteria in the urine
[8]. The RCT found benefit for symptoms with antibiotic
over no antibiotics - even when conventional wisdom had
held that they were not infected by bacteria (but had what
might have been called 'urethral syndrome' in the past)
[8].
On the other side of the coin, women with urinary
infections randomised to delay taking antibiotics by two
days suffer only about a day or two more of symptoms [9].
In other words, we can think of UTI as a spontaneously
remitting disease, if we use symptoms (rather than steril-
ity of the urine[10]) as the end-point, which is accelerated
by the use of antibiotics.
A prognosis study has shown that the psychological
state of the woman is important - those with 'somatisa-
tion' (exaggerated feelings of symptoms ) are likely to
overcome their symptoms slower, while those who per-
ceived the doctor to be positive about quickly overcoming
symptoms recovered faster [9].
Like so much in medicine, the arena is messy, with
many factors influencing recovery.
One thing is clear: whether treatment should be aimed
at eliminating bacteria from the urine or not, certainly
treatment of the symptoms warrants attention.
The evidence
This is then a fertile time to think about using symptoms
control rather than 'bacterial eradication' as an approach.
Urinary alkalinisers self management
It has been traditional to use urinary alkalinisers in the
past as symptomatic relief (by the simple expedient of
taking sodium or potassium bicarbonate or other alkaline
by mouth) [11]. This is remarkably poorly evaluated in
the medical literature [12]. An observational study found
symptom severity within each woman's illness was not
associated with increases in urinary pH, suggesting alka-
linising the urine is unlikely to reduce symptoms [12]. A
factorial randomised trial which randomised yielded no
difference to those randomised to advice to use bicarbon-
ate or not [5].
Cranberry juice self management
Although cranberry juice is a well used 'alternative and
complementary medicine' for urinary tract infection, and
there is weak and contradictory evidence it might act as a
preventive agent [13], there is insufficient good quality
trial evidence to support its use as a treatment [14]. One
good RCT has been published recently to suggest that it
is not [5].
Non-steroidal anti-inflammatory (NSAIDs) drugs
These are commonly used for pain and inflammatory
conditions, and, although NSAIDs have adverse effects,
they are regarded as sufficiently safe to be available in
most jurisdictions over-the-counter without prescription.
The pragmatic trial published this month in BMC Med-
icine by Bleidorn and colleagues [15] randomised antimi-
crobial treatment against symptomatic treatment (in the
form of a non-steroidal anti-inflammatory drug) for uri-
nary symptoms. The treatments were equivalent not just
in the outcome of symptoms (which might have been pre-
dicted), but in the outcome of subsequent urinary infec-
tions. Why is this revolutionary? Because it turns on its
head the notion that we should regard urinary infections
as primarily an infectious process that needs sterilisation
of the urine to effect resolution.
It used to be thought that urinary infections were suffi-
ciently unusual and bizarre to requite extermination of
the bacterial intruder. However two things have altered
this approach. Firstly we recognise that some people
(especially the elderly) often have bacteriuria with no ill
effect, including no symptoms: treating them with antibi-
otics achieves only bacterial resistance. More recently we
have come to realise that women who have urinary symp-
toms but no evidence of bacterial infection detected on
urinary dip-stick - women who would have accordingly
been denied antibiotics using traditional treatments -
benefit symptomatically from antibiotics [8]. Guidelines
have adjusted to this in some quarters[16] (but not
all[17]).
Conclusions
Competing interests
The author declares that they have no competing interests.
Authors' information
CDM is professor of primary care research at Bond University, Australia. He is 
also the coordinating editor of the Cochrane Collaboration's acute respiratory 
infection group.
Author Details
School of Medicine, Faculty of Health Sciences, Bond University, Queensland 
4229, Australia
Received: 15 April 2010 Accepted: 26 May 2010 
Published: 26 May 2010
This article is available from: http://www.biomedcentral.com/1471-2296/11/42© 2010 D l M r; l censee BioMed Central Ltd. is an Open Acces  article distribu ed under th  terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.BMC Family Pract  2010, 11:42
Del Mar BMC Family Practice 2010, 11:42
http://www.biomedcentral.com/1471-2296/11/42
Page 3 of 3References
1. Hooton TM, Scholes D, Hughes JP, Winter C, Roberts PL, Stapleton AE, 
Stergachis A, Stamm WE: A prospective study of risk factors for 
symptomatic urinary tract infection in young women.  N Engl J Med 
1996, 335:468-474.
2. Moore EE, Hawes SE, Scholes D, Boyko EJ, Hughes JP, Fihn SD: Sexual 
intercourse and risk of symptomatic urinary tract infection in post-
menopausal women.  J Gen Intern Med 2008, 23:595-599.
3. Krieger JN: Urinary tract infections what's new?  J Urol 2002, 
168:2351-2358.
4. Jackson SL, Boyko EJ, Scholes D, Abraham L, Gupta K, Fihn SD: Predictors 
of urinary tract infection after menopause a prospective study.  Am J 
Med 2004, 117:903-911.
5. Little P, Turner S, Rumsby K, Warner G, Moore M, Lowes JA, Smith H, 
Hawke C, Turner D, Leydon GM, Arscott A, Mullee M: Dipsticks and 
diagnostic algorithms in urinary tract infection development and 
validation, randomised trial, economic analysis, observational cohort 
and qualitative study.  Health Technol Assess 2009, 13:iii-iv. ix-xi, 1-73
6. Deville WL, Yzermans JC, van Duijn NP, Bezemer PD, Windt DA van der, 
Bouter LM: The urine dipstick test useful to rule out infections. A meta-
analysis of the accuracy.  BMC Urol 2004, 4:4.
7. Editorial: Urethral syndrome.  BMJ 1968, 2:192.
8. Richards D, Toop L, Chambers S, Fletcher L: Response to antibiotics of 
women with symptoms of urinary tract infection but negative dipstick 
urine test results double blind randomised controlled trial.  BMJ 2005, 
331:143.
9. Little P, Merriman R, Turner S, Rumsby K, Warner G, Lowes JA, Smith H, 
Hawke C, Leydon G, Mullee M, Moore MV: Presentation, pattern, and 
natural course of severe symptoms, and role of antibiotics and 
antibiotic resistance among patients presenting with suspected 
uncomplicated urinary tract infection in primary care observational 
study.  BMJ 2010, 340:b5633.
10. Arav-Boger R, Leibovici L, Danon YL: Urinary tract infections with low 
and high colony counts in young women. Spontaneous remission and 
single-dose vs multiple-day treatment.  Arch Intern Med 1994, 
154:300-304.
11. Therapuetic Guidelines  2009 [http://www.tg.org.au/
index.php?sectionid=1]. Therapuetic Guidelines Limited ed. Melbourne 7 
Mar 2010
12. Brumfitt W, Hamilton-Miller JM, Cooper J, Raeburn A: Relationship of 
urinary pH to symptoms of 'cystitis'.  Postgrad Med J 1990, 66:727-729.
13. Jepson RG, Craig JC: Cranberries for preventing urinary tract infections.  
Cochrane Database Syst Rev 2008:CD001321.
14. Jepson RG, Mihaljevic L, Craig J: Cranberries for treating urinary tract 
infections.  Cochrane Database Syst Rev 2000:CD001322.
15. Bleidorm J, Gagyor I, Kochen M, Wegscheider K, Hummers-Pradie E: 
Symptomatic treatment (ibuprofen) or antibiotics (ciprofloxacin) for 
uncomplicated urinary tract infection? - Results of a randomized 
controlled pilot trial.  BMC Medicine 2010, 8:30.
16. Scottish Intercollegiate Guidelines Network (SIGN): 88: Management of 
suspected bacterial urinary tract infection in adults.  2006 [http://
www.sign.ac.uk/pdf/sign88.pdf]. (accessed 5 Apr 2010)
17. American College of Obstetricians and Gynecologists (ACOG): Treatment 
of urinary tract infections in nonpregnant women (ACOG practice 
bulletin; no. 91).  2008 [http://www.guideline.gov/summary/
summary.aspx?doc_id=12628&nbr=006536&string=urinary+AND+infecti
on]. (accecssed 5 April 2010)
18. Fowler G: The role of the primary health care team.  J R Soc Med 1986, 
79:633-636.
19. Stott NC: William Pickles Lecture 1993. When something is good, more 
of the same is not always better.  Br J Gen Pract 1993, 43:254-258.
20. Del Mar C, Glasziou P: Upper respiratory tract infection.  Clin Evid 2004, 
11:1956-1965.
Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2296/11/42/prepub
doi: 10.1186/1471-2296-11-42
Cite this article as: Del Mar, Urinary tract infections in healthy women: a rev-
olution in management? BMC Family Practice 2010, 11:42


Crossref

American College of Obstetricians and Gynecologists (ACOG): Treatment of urinary tract infections in nonpregnant women (ACOG practice bulletin;

Bouter LM: The urine dipstick test useful to rule out infections. A metaanalysis of the accuracy. BMC Urol

Cranberries for treating urinary tract infections. Cochrane Database Syst Rev

Danon YL: Urinary tract infections with low and high colony counts in young women. Spontaneous remission and single-dose vs multiple-day treatment. Arch Intern Med

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The role of the primary health care team.

Urinary tract infections what's new?

When something is good, more of the same is not always better.

https://pure.bond.edu.au/ws/files/31147200/Urinary_tract_infections_in_healthy_women.pdf

Urinary tract infections in healthy women: a revolution in management?

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